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DR.  HORACE  WELLS. 
Discoverer  of  Anaesthesia. 

(Nevius) 


LECTURES 


ON 


General  Anaesthetics 
in  Dentistry 

Advocating  Painless  Dental  Operations 
By  the  use  of 

Nitrous  Oxid,  Nitrous    Oxid  and  Oxygen,  Chloroform 
Analgesia,  Ethyl  Chloride  and  Somnoform 

By 

WII.I.IAM   H.  De  ford,  B.A.,  D.D.S.,  M.D.,  M.A., 

Late  Professor  of  Oral  Pathology  and  Oral  Surgery,  College  of 
Dentistry,  State  University  of  Iowa;  Lecturer  on  AnEESthetics 
and  Dental  Surgery,  Drake  University  Medical  College; 
Member  of  Ninth  International    Medical  Congress; 
National  Dental  Association;   Member  and  Ex- 
President  Iowa  State  Dental  Society;   Hon- 
orary Member  Missouri  and  South  Da- 
kota State  Dental   Societies;    Presi- 
dent Des  Moines  District  Den- 
tal Society;    President  Iowa 
State   Board   of   Dental 
Examiners,  etc.,  etc. 


JOHN  T.  NOLDE  MFG.  CO. 

Publishers 

St.  Louis  Kansas  City  Mexico  City 


Copyrighted,  1908 

By 

William  H.  De  Ford. 


^G. 


Press  of 

Franklin  Hudson  Publishing  Co., 

Kansas  City,  Mo. 

1908. 


The  reason  the  patient  so  rarely  goes  beyond  the 
border-line  lies  not  so  much  in  the  agent  employed  as 
in  the  skill  of  the  experienced  ansesthetizer,  who  knows 
the  properties  of  the  drug  he  uses;  who,  after  a  thor- 
ough examination,  has  taken  all  [precautions ;  who  [fore- 
sees all  possible  "accidents";  who  will  not  trust  to  luck; 
and  who  remains  vigilant  throughout  and  until  the 
patient  returns  to  consciousness. — The  Medical  Times, 
Jan'y,  1908. 


DEDICATION. 

To 

JESSIE  RITCHEY  D13  FORD,  D.D.S., 

In   recognition  of    her    ability  as  a  skilled    anaesthetist 
and  valued  co-laborer,  I  dedicate  this  volume. 


PREFACE. 

At  the  request  of  Dr.  Burton  Lee  Thorpe,  associate 
•editor  of  The  Dental  Brief,  the  writer  prepared  for  that 
journal  a  series  of  articles  entitled  "Anresthetics  in 
Dentistry."  From  time  to  time  during"  their  publica- 
tion numerous  letters  were  received  from  all  over  this 
country  and  abroad  inquiring  if  these  articles  vrould 
he  published  in  book  form. 

S«)  many  inquiries  of  this  kind  have  come  to  hand 
as  to  create  the  impression  that  a  practical  treatise  on 
anesthetics  was  very  much  needed.  Instead  of  repro- 
ducing in  book  form  what  has  alread}^  been  printed  in 
the  Brief,  the  author  has  used  those  articles  as  a  skele- 
ton about  which  he  has  woven  the  fabric  which  consti- 
tutes these  brief  lectures. 

The  object  of  this  book  is  to  give  the  busy  dentist 
a  working  knowledge  of  such  general  anaesthetics  as 
can  be  used  to  advantage  in  daily  practice.  With  this 
end  in  view,  the  author  has  prepared  what  he  has  to  say 
in  the  form  of  brief  lectures.  The  "how"'  is  dwelt  upon 
more  than  the  "Avhy" ;  in  other  words,  it  is  simply  a 
practical  treatise,  and  not  a  theoretical  exposition. 

The  lecture  st^de  enables  the  author  to  talk  directly 
to  the  individual  just  as  is  done  in  the  class-room  and 
to  repeat  and  emphasize  from  time  to  time  the  more 


important  and  essential  things,  which  is  not  permissible 
in  a  text-book. 

Hewitt  has  been  quoted  frequently ;  his  text-book 
en-titled  ''Anaesthetics.""  in  my  opinion,  is  the  best  that 
has  ever  been  M-ritten  on  this  subject.  Brunton,  Luke, 
Buxton,  Crile  and  others  have  been  consulted,  and, 
likewise,  papers  and  clinical  reports  nublished  in  The 
British  Medical  Journal,  Journal  of  the  American  Medi- 
cal Association,  current  medical  literature  in  medical 
and  dental  journals,  etc.,  etc. 

The  author  is  also  indebted  to  the  S.  S.  White 
Dental  Alanufacturing  Company,  E.  de  Trey  &  .Sons, 
the  Lennox  Chemical  Company,  A.  C.  Clark  &: 
Company,  Teter  Manufacturing"  Company,  and  Dr. 
Laird  W.  Nevius  for  the  cuts  of  the  various  dental  ap- 
pliances used  in  these  pages. 

Hotel  Victoria,  Des  3kioines,  Iowa,  April,  1908. 


CONTENTS. 

LECTURE  I. 

Has  the  Dental  Surgeon  the  Right  to  Admixistek. 
General  Anesthetics? 

Page 
Potentiality  of  the  dental  diploma. — Employment  of  drugs 
other  than  anaesthetics. — ^The  oldest  dental  college  in  the 
world. — Dr.  Chapin  A.  Harris  endeavors  to  establish  chairs 
of  operative  and  mechanical  dentistry  in  the  Maryland 
University  Medical  College. — Dentists  may  become  mem- 
bers of  the  American  Medical  Association. — The  dentist 
should  surround  himself  with  every  possible  safeguard. — 
Dentist  would  not  be  liable  for  a  death  which  might  result. — 
Dentist  is  not  held  to  insure  the  result  of  his  work 13 

LECTURE  II. 

The  Value  of  General  Anesthetics  to  the  Dental 
Surgeon. 

Anaesthetics  are  employed  to  prevent  pain  and  to  avoid 
sho(?k. — Dangerous  to  submit  patients  to  intense  pain  be- 
yond certain,  limits. — Employ  anaesthetics  to  facilitate 
operating. — Saves  the  patient  suffering  and  nerve  strain. — 
A  visit  to  Dr.  Austin  C.  Hewett's  office. — Conditions  in 
which  general  anaesthetics  can  be  used  to  advantage.  ....      21 

LECTURE  III. 

To  Whom  Is  It  Safe  to  Administer  an  Anesthetic? 

Invalids  and  patients  in  poor  health  usually  good  subjects. — 
Opinions  of  Ochner,  Luke,  Richardson  and  Brunton. — 
Ether  and  chloroform  contra-indications.  —  The  strong, 
healthy  and  vigorous  more  liable  to  accidents  than  the 
weak  and  frail. — -Inexperience,  ignorance  and  carelessness 
responsible  for  deaths. — Importance  of  watching  respira- 
tion       31 

LECTURE  IV. 

Elements  of  Danger. 

In  civic  matters,  ignorance  of  the  law  excuses  no  man. — Deaths 
result  from  ignorance  of  ansesthetic  symptoms  and  stages. 
— Medical  and  Dental  Colleges  are  at  fault. — Case  illus- 
trating ignorance  — Anaesthetics  in  themselves  not  so  dan- 
gerous as  ignorant  anaesthetists. — Carelessness  of  hosipital 
authorities. — Alice  Magaw. — -Buxton  and  Galloway  arraign 
Medical  Colleges. — Length  of   duration  of   anaesthesia  an 

(■        element  of  danger. 40 


8  Conients. 

LECTURK  \'. 

Shock. 

Page 

Shock  defined. — -Causes  are  psychical  and  physical. — Psychical 
causes  defined. — -A  death  from  shock. — ^Deaths  resulting 
from  fear. — Chloroform  experiments  on  plants  and  animals. 
— ^Shock  resulting  from  external  pressure. — Anaesthesia  in- 
duction before  the  introduction  of  general  anaesthetics. — 
Many  who  are  hung  and  drowned  die  from  shock. — Exter- 
nal pressure  exerted  by  clothing. — Spasm  of  the  glottis. — 
Death  resulting  from  blood  collecting  in  the  throat. — 
Nausea  during  nitrous  oxid  administration. — -Shock  and 
death  resulting  from  operating  during  partial  anaesthesia. — 
Chloroform  idiosyncrasy 50 

I,ECTURE  VT. 

Dental  Fatigue. 

Dental  fatigue  and  shock  differ  only  in  degree. — Dread  of 
dental  operations. — Illustrative  cases. — Handling  of  such 
patients. — Nitrous  oxid,  somnoform,  ethyl  chloride,  or 
chloroform  recommended. — Christian  Science. — Case  of  a 
Christian  Science  healer. — Hypnotism. — Hypnotism  illus- 
trated.— Cases  illustrating  dental  fatigue  and  their  treat- 
ment       67 

LECTURE  VII. 

Elements  op  Success.  • 

The  operating-room. — The  rest-room. — ^Preparation  of  the 
patient  by  the  assistant. — Remove  corset  in  all  cases. — 
Attention  to  bladder. — .\llay  fear.^ — ^Suggestion. — Illustra- 
tive case. — Assistant's  duties. — Never  anaesthetize  a  wom- 
an without  witnesses. — Illustrative  case. — Importance  of 
quiet  in  operating-room.  —  Suggestion  after  operating. — 
Prevent  blood  from  being  swallowed.— Objections  to  hurry- 
ing resuscitation. — Dental  chair  responsible  for  many  fail- 
ures.— The  best  anaesthetic  chair 


I,P:CTURE  VIII. 
Relative  SAPirrv  of  General  Anesthetics. 


79 


Nitrous  oxid  and  oxygen  tlie  safest  of  all  anaesthetics. — -Chlo- 
roform the  most  dangerous. — Statistics  prepared  by  Jul- 
liard,  Ormsby,  St.  Bartholemew's  Ho.spital,  Luke. — Unre- 
liability of  statistics. — Teter's  prolonged  case  of  anaes- 
thesia—Nitrous oxid  and  oxygen  handicapped. — Som- 
noform.— Ethyl  cliloridc  popular. — Carelessness  of  chloro- 
form administration. — Utterly  impossible  to  obtain  correct 
percentage  of  deaths  caused  by  anaesthetics — Anaesthetic 
deaths  exaggerated 92 


Contents.  9 

LECTURIv  IX. 
Nitrous  Oxid  Gas. 

Page 
Part  played  by  Priestley,  Sir  Humphry  Davy,  Wells  and  An- 
drews.— Dr.  Burton  Lee  Thorpe  settles  the  controversy. — 
Colton's  lecture. — \\^ells  discovers  anaesthetic  properties  of 
nitrous  oxid. — Dr.  Riggs  extracts  tooth  for  Wells. — Physical 
properties  of  nitrous  oxid. — Anaesthetic  action  of  nitrous 
oxid. — Claude  Martin's  experiments, — Apparatus  for  man- 
ufacturing nitrous  oxid. — Nitrous  oxid  cylinders. — Weight 
of  nitrous  oxid  gas. — Nitrous  oxid  appliances. — -S.  S. 
White's,  A.  C.  Clark's,  and  Teter's  appliances  illustrated .  .    103 

LECTURE  X. 

Nitrous  Oxid  Gas  Administration. 

Difficult  to  administer.- — An  assistant  necessary. — Arrange- 
ment of  patient  in  the  chair. — Mouth-prop  is  important. — 
Average  time  of  induction. — Care  in  selecting  patients.— 
Adjustment  of  the  inhaler. — Amount  of  nitrous  oxid  neces- 
sary.— Ansmics  susceptible. — Alcoholics  require  more. — 
First  stage  of  anesthesia  symptoms. — Second  stage  of 
anaesthesia  symptoms 116. 

LECTURE  XI. 

Nitrous  Oxid  Gas  Administration — Continued. 

Third  stage  of  anaesthesia  symptoms. — Stage  of  surgical  anaes- 
thesia. —  The  respiration.  —  The  circulation.  —  Muscular 
phenomena. — -Fourth  stage  of  anaesthesia  symptoms. — Ef- 
fects of  an  overdose  ■ — Description  of  the  action  of  nitrous 
oxid  in  thirteen  fatalities. — Nitrous  oxid  warmed. — Kindly 
by  patient. — Administration 128 

LECTURE  XIL 
Nitrous  Oxid  and  Oxygen. 

Oxygen  a  supporter  of  life. — Experiments  by  Priestley  and 
Demarquay. — Andrews  of  Chicago,  the  first  to  use  this 
combination. — Safest  anaesthetic  known.- — Hillischer's  esti- 
mate of  its  safet3^ — Apparatus. — Percentage  of  oxygen 
necessary. — Air  a  disadvantage. — Administration.  —  The 
Brown  anaesthetizer  illustrated.  —  An  unobstructed  air- 
way requisite. — The  four  anaesthetic  stages. — Anaesthetic 
signs 141 


10  Contents. 

LECTURE  XIII. 

Nitrous  Oxid  and  Oxygen  in  Operative  Dentistry. 

Nitrous  oxid  and  oxygen  in  all  painful  operations  on  the  teeth. 
— Teter's  appliance  for  administering  nitrous  oxid  and  oxy- 
gen and  other  general  anaesthetics  illustrated. — Its  use  in 
sensitive  cavity  preparation. — Removal  of  pulps. — Shaping 
teeth  for  crowns  and  abutments.  —  Opening  into  teeth 
affected  with  pericementitis  and  acute  alveolar  abscess. — 
All  painful  and  fatiguing  operations  on  the  teeth. — Admin- 
istration.— Suggestions  to  the  patient. — Description  of  a 
clinical  case. — ^The  Teter's  nasal  inhaler  illustrated 155 

LECTURE  XIV. 

Ethyl  Chloride. 

First  used  by  Hejrfelder. — History. — Requisite's  of  a  perfect 
anaesthetic. — Chemistry  of  ethyl  chloride. — Safety  of. — - 
Action  on  the  circulation. — Luke's  estimate  of. — Adminis- 
tration— Tubes  and  capsules. — General  and  local  anaes- 
thetics.— Inhalers.  — ■  Action  of  patient  under. — Neurotic 
women  and  alcoholics. — Cyanosis  — Supervening  nausea. — 
Headache 162 

LECTURE  XV. 

Somnoform. 

History. — Dr.  G.  Rolland  the  discoverer. — How  an  ideal  anaes- 
thetic should  act. — Ethyl  chloride.  —  Methyl  chloride. — 
Formula. — Induction  period. — Available  period  of  anaes- 
thesia.— As  to  safety. — Stage  of  surgical  anaesthesia  in- 
duced by  nitrous  oxid  more  dangerous  than  stage  of  sur- 
gical anaesthesia  induced  by  somnoform. — Tubes  and  cap- 
sules — Nausea  following  use  of  tubes. — de  Trey's  inhaler 
,  described  and  illustrated. — Stark's  inhaler  described 173 

LECTURE  XVI. 

vSoMNOFORM  Administration. 

Physiological  advantages — Circulatory  action. —  Stimulating 
effect. — Rarely  depresses. — Respiration  in. — Holding  the 
breath  in. — A  twenty-five  -  minute  anaesthesia. — Illustra- 
tive cases. — Not  cumulative. — No  change  in  the  amount 
of  haemoglobin  or  in  the  number  of  leucocytes.  —  Non- 
irritating  to  mucous  membrane  and  nerves. — Syncope  of 
Duret.— No  swelling  of  tongue. — Nausea  rare.  —  Deeper 
anaesthesia  than  necessary.^ — Air  an  ad  vantage. ^Normal 
breathing.  —  Illustrative  case.  —  Nausea  cases. — Nausea 
from  swallowing  blood. — Headache  following. — Carbon' 
dioxide '. 188 


Contents.  11 

LECTURE  XVII. 

SOMNOFORM    AUMIXISTRATION. 

•  Page 

Illustrated  by  a  case. — -Easiest  of  all  anaesthetics  to  adminis- 
'ter. — Exclusion  of  air.  —  Use  of  de  Trey's  inhaler. — ■ 
Method  discouraged. — Admission  of  air. — In  multiple  ex- 
tractions.— Normal  breathing. — Other  than  mouth  opera- 
tions.— An  ansemic  patient. — A  plethoric  patient. — 
Stark's  inhaler. — -A  hysterical  patient. — A  nervous  girl. — 
Stark's  inhaler  in  nausea  cases. — Stark's  inhaler  illustra- 
ted.— A  somnoform  capsule  illustrated. — A  box  of  somno- 
form  capsules  illustrated 200 

LECTURE  XVIII. 

Somnoform  Admixistr.\tiox — Continued. 

Oxygen  deprivation. — Excitement  under. — Never  restrain  pa- 
tient.— A  case  in  practice. — Excitement  usually  after  in- 
duction.— Illustrative  cases. — In  an  asthmatic— A  very 
nervous  patient — An  over  -  anaesthetized  patient. — Anal- 
gesia following. — Illustrative  case. — A  dead  pulp. — 
Effects  of  tobacco,  chloral,  morphine,  alcohol,  etc. — 
Patient  intoxicated. — A  pronounced  alcoholic. — Combina- 
tion of  alcohol  and  morphine. — Aneesthetic  symptoms. — 
Dental  uses  of.- — Sensitive  cavity  preparation. — -Preparing 
tooth  for  crown.  —  In  acute  pericementitis. — In  acute 
alveolar  abscess.  —  For  exposing  and  removing  dental 
pulps. — Evacuating  pus. — Lancing  gum. — Curetting  and 
cauterizing  pus  pockets. — Opening  into  antrum. — Ampu- 
tating roots  -=-For  dentigerous  cysts  : — Alveolar  and  max- 
illary necrosis. — Extraction  of  teeth. — Illustrative  cases.  .    215 

LECTURE  XIX. 

CHLOROFORir   AXALGESIA. 

Dr.  Austin  C.  Hewett,  of  Chicago,  first  advocate. — Experiment- 
ed upon  himself. — Committee  appointed  to  visit  his  of- 
fice.— Report  of  committee. — Illustrative  cases.— Dr.  Hew- 
ett's  attitude  in  relation  to  chloroform. — How  adminis- 
tered.— At  variance  with  all  recognized  authorities. — Rec- 
ommendations of  the  committee 236 

LECTURE  XX. 

ETHER  AND  Chloroform. 

These  agents  should  not  be  used  by  the  dental  surgeon  to  in- 
duce surgical  anaesthesia. — Hospital  recommended  for  all 
ether  and  chloroform  cases. — Objections  to  their  use  in  the 
office. — Chloroform  deaths  in  the  dental  chair. — Advan- 
tages of  a  surgical  chair. — Anaesthetist  and  nurse. — Ether 


12  Contents. 

Page 

safer  than  chloroform. — Dentist  should  know  physiological 
action  of  ether  and  chloroform. — Should  know  how  to  ad- 
minister these  agents. — History  and  physical  properties 
of  ether. — Close  and  open  methods  of  administration.—- 
Luke's  estimate  of  American  anaesthetists  and  anaesthesia. 
— Protection  of  eyes  and  face. — History  and  physical  prop- 
erties of  chloroform. — Chloroform  tests. — Preparation  of  ■ 
the  patient. — Chlorofoform  administration.  —  Hewitt's 
table  showing  anaesthetic  stages 249 

LECTURE  XXL 

DiFFI-CULTlES   AND    DANGERS    INCIDENT    TO     ADMINISTER- 
ING General  Anesthetics  in  Dental  Practice, 
AND  How  TO  MEET  Them. 

Allay  fear. — Remove  the  corset. — Handling  children. — Mental 
and  physical  excitement.- — Case  of  a  cigarette  fiend. — Dan- 
gers that  may  arise. — Respiratory  arrest.  —  Mechanical 
and  paralytic. — Toxic,  mechanical,  and  reflex  causes. — 
Mechanical  causes  and  treatment 271 

LECTURE  XXII. 

Difficulties   and   Dangers  Incident  to   Administer- 
ing General  Anesthetics  in  Dental  Practice 
and  How  to  Meet  Them — Continued. 

Presence  of  foreign  matter  in  the  throat. — Blood,  mucus, 
vomit,  roots  and  teeth  in  the  throat. — Cases  reported  of 
foreign  matter  in  the  throat.  —  Respiratory  arrest  the 
result  of  paralysis  of  the  respiratory  center.  —  Artifi- 
cial respiration.  —  Sylvester's  method.  —  Marshall  Hall's 
method. — Drugs  not  of  much  avail. — Circulatory  failure. 
— Treatment  of  circulatory  failure. — Horizontal  position. 
— Heart  massage. — ^Tongue  traction. — ^Wet  towels. — Am- 
monia nitrate,  amyl  nitrite,  strychnia,  adrenalin,  caflfine. — 
Equipment  recommended 235 


General  Ancesihetics  in  Dentistry.  13 


LECTURE  I. 

Has  the  Dental  Surgeon  the  Right  to  Administer 
General  Anaesthetics? 

The  mind  of  the  dental  surgeon  is  clear  as  to  his 
right  to  put  into  practice  everything  taught  in  his  alma 
mater,  except  general  an£esthetics.  He  is  taught  opera- 
tive dentistry,  and  operates  on  the  teeth ;  he  is  taught 
prosthetic  dentistry,  and  restores  lost  organs;  he  is 
taught  orthodontia,  and  corrects  irregularities  of  the 
teeth ;  he  is  taught  materia  medica  and  therapeutics^ 
and  prescribes  constitutional  remedies ;  he  is  taught  the 
theory  and  action  of  general  anaesthetics — but  employs 
them  not. 

He  hesitates  not  a  moment  to  inject  cocaine  hypo- 
dermically  into  the  gingival  tissue,  a  procedure  that  is 
fraught  with  many,  many  times  the  risk  he  would  be 
taking  in  administering  nitrous  oxid  gas  or  somnoform. 
Surely,  if  the  dental  diploma  is  worth  anything,  if  it 
means  anything,  if  there  is  any  potentiality  in  it,  it 
carries  with  it  the  right  to  do  those  things  in  the  office 
of  the  possessor  which  are  taught  in  the  curriculum  of 
his  alma  mater. 

In  all  other  departments,  dentistry  has  made  won- 
derful progress,  outstripping  almost  every  other  profes- 
sion in  the  matter  of  advancement;  yet,  in  this  partic- 


14  General  Ancesthetics  in  Dentistry. 

iilar,  branch,  anaesthetics,  which  should  have,  by  right 
of  discovery  and  inheritance,  excelled  all  other  special- 
ties of  medicine,  the  dentist  has  been  a  laggard  and  a 
coward.  By  right  of  discovery  and  inheritance,  because 
the  greatest  benefactor  the  human  race  has  ever  known, 
Horace  Wells,  the  discoverer  of  surgical  anaesthesia, 
was  a  dentist,  Morton,  another  dentist,  was  the  first 
to  discover  the  anaesthetic  properties  of  sulphuric 
ether;  and  it  was  Roland,  dean  of  the  Dental  School 
of  Bordeaux,  France,  who  experimented  with  various 
anaesthetic  mixtures  and  gave  us  the  combination 
which  he  designates  somnoform.  Had  the  rank  and  file 
of  the  dental  profession  followed  in  the  footsteps  of 
.Wells  and  Morton  and  made  practical  application  of  the 
truths  these  men  gave  us,  dentistry  would  to-day  be 
a  century  in  advance  of  its  present  status. 

It  is  said  of  the  Savior,  He  came  unto  His  own, 
and  His  own  received  Him  not ;  nevertheless,  the  de- 
spised, the  rejected  One  became  the  Light  of  the  A\'orld. 
So  it  has  been  with  anjesthetics.  The  world  is  in- 
debted to  members  of  the  dental  profession  for  the  dis- 
coverv  of  the  anesthetic  properties  of  nitrous  oxid  gas 
and  ether;  these  anaesthetics,  rejected  by  the  dental 
surgeon,  in  the  hands  of  the  general  surgeon  have  be- 
come the  greatest  boon  ever  bes-Luwed  upon  sufTering 
humanity.  As  the  Jews  will  surely  return  to  Jerusale  i), 
•we  should  return  to  our  own,  claim  it,  appropriate  it, 
rnake  use  ot  it,  and  reap  the  rewards. 
..  Surely  if  anyone  is  entitled  to  administer  auccs- 
thetics',itis  tlie  dentist ;  not  only  because  of  the  prior- 
ilv  of  discovery.  Inil  because  of  the  necessary  pain  in- 


General  AncBsihetics  in  Dentistry.  15 

flicted  to  do  his  work  properly.  Has  the  dental  surgeon 
the  legal  right  to  administer  anaesthetics?  Certainly. 
If  he  has  received  proper  instruction  in  regard  to  the 
chemistry,  physiological  action,  properties,  and  be- 
havior of  anesthetics;  if  he  has  attended  lectures  on 
physical  diagnosis,  and  passed  a  successful  examination 
in  materia  medica  and  therapeutics,  and  possesses  a 
diploma  from  a  reputable  dental  college,  why  not?  The 
intelligent,  progressive  dentist  in  the  treatment  of  in- 
cipient alveolar  abscess  prescribes  cathartics,  diuretics, 
diaphoretics,  etc. ;  in  the  treatment  of  pyorrhoea,  diet- 
ary measures  and  eliminants ;  in  facial  neuralgia,  ano- 
dynes and  tonics ;  in  pulpitis,  opiates  and  soporific-  ; 
in  dental  caries,  antacids  and  germacides — indeed,  his 
materia  medica  vocabulary  is  as  extensive,  if  not  more 
so,  than  that  of  the  ophthalmologist,  rhinologist  or 
laryngologist ;  yet  the  dental  practitioner  hesitates  to 
avail  himself  of  the  usefulness  of  general  ana^stheiics. 
Had  Dr.  Chapin  A.  Harris  succeeded  in  making 
good  the  ambition  of  his  life,  this  lecture  would  have 
been  unnecessary.  Dr.  Harris  was  the  founder  of  the 
Baltimore  College  of  Dental  Surgery,  the  oldest  dental 
college  in  the  world.  In  1837,  Dr.  Harris  appeared  be- 
fore the  trustees  of  the  University  of  Alaryland  Medical* 
College  and  proposed  that  they  should  add,  to  their 
curriculum  the  chairs  of  operative  and  mechanical  den- 
tistry, and  those  desiring  to  prepare  themselves  for  the 
practice  of  dentistry  should  take  the  work  of  these  two 
chairs  in  addition  to  the  medical  studies.  His  proposi- 
tion met  \\\i\\  flat  refusal.  The  following  year  he 
made  another  attempt,  but  the  trustees  denied  his  re- 


16  General  Ancesihetics  m  Dentistry. 

quest;  so,  in  1839,  he  organized  the  Baltimore  College 
of  Dental  Surgery.  Had  Chapin  A.  Harris  been  suc- 
cessful in  establishing  dental  chairs  in  Maryland  Uni- 
versity Medical  School,  every  dentist  would  have  been 
a  medical  man  and  the  D.  D.  S.  degree  unknown.  In 
keeping  with  such  terms  as  otologist,  rhinologist,  neu- 
rologist, etc.,  we  would  have  been  designated  odon- 
tologists,  and  would  have  practiced  under  the  M.  D. 
degree,  and  the  question  as  to  the  right  of  dental  sur- 
geons to  administer  anaesthetics  would  never  have 
been  raised. 

The  dental  surgeon,  it  is  true,  has  never  availed 
himself  of  all  of  his  rights  and  privileges.  He  has 
not  shown  that  broad  professional  spirit  which  should 
dominate  him  ;  he  has  not  clasped  hands,  as  he  should 
have  done,  and  become  one  with  his  brother,  the  medi- 
cal man. 

The  subsequent  conduct  of  the  medical  profession 
has  been  as  magnanimous  as  it  had  been  short-sighted 
and  narrow,  and  it  appears  as  though  they  had  tried 
to  right  what  might  be  denominated  the  crime  of  1837- 
38,  when  the  medical  faculty  of  the  Maryland  Univer- 
sity refused  to  accept  dental  students  on  the  terms  pro- 
posed by  Dr.  Harris. 

When  the  Ninth  International  Medical  Congress 
convened  in  Washington  in  1889,  a  Dental  Section  was 
organized,  thus  placing  the  dental  surgeon  on  an  equal 
footing  with  the  opthalmologist,  laryngologist,  gynae- 
cologist and  other  medical  specialties.  Of  the  eighteen 
sections  constituting  that  congress,  no  man  was  ever 
before  admitted  to  membership  without  the  degree  of 


General  AncBsthetics  in  Dentistry.  17 

doctor  of  medicine.  About  this  time,  the  American 
Medical  Association  added  a  Section  on  Stomatolo^, 
the  membership  of  which  is  composed  of  prominent 
dental  surgeons.  In  case  of  a  death  during  anaesthesia, 
would  a  coroner's  jury  or  a  court  of  justice  say  that  a 
member  of  the  Inter-National  Medical  Congress  or  a 
member  of  the  American  Medical  Association  had  not 
the  right  to  administer  an  anaesthetic?  Membership 
in  these  associations  is  open  to  you,  and  if  you  are  not 
a  member  of  the  dental  section  of  one  or  both  of  these 
organizations,  you  have  only  yourself  to  blame. 

The  right  to  administer  an  anaesthetic,  whether  In^ 
a  physician  or  a  dentist,  depends  fundamentally  upon 
the  possession  of  the  requisite  knowledge,  skill  and  ex- 
perience. A  dentist  undoubtedly  has  the  right  to  ad- 
minister anaesthetics  in  his  practice  if  he  is  competent 
to  do  so.  But  a  dentist  has  not  the  right  to  administer 
anassthetics  unless  he  is  familiar  with  their  effects 
and  can  show  his  proficiency  in  this  respect.  If  a  den- 
tist should  have  an  accident  or  a  fatality  of  such  a  na- 
ture as  a  coroner's  jury  or  the  courts  of  justice  would 
take  into  account,  his  right  to  administer  anaesthetics 
would  be  more  strictly  called  into  question  than  if  a 
physician  should  have  a  similar  accident.  In  the  case 
of  the  physician,  the  community  generally  take  it  for 
granted  that  he  is  competent  and  experienced  Avith 
anaesthetics ;  whereas,  if  a  dentist  had  a  mortality  in 
his  office,  they  would  probably  think  that  he  was  not  so 
competent  and  experienced  in  the  use  of  anaesthetics. 
Hence,  the  dentist  who  is  administering  anaesthetics, 
or  who  contemplates  doing  so,  should  surround  him- 


18  General  Ancesihetics  in  Dentistry. 

self  with  every  possible  safeguard.  If  he  is  a  recent 
g-radiiate,  or  has  onl}^  been  in  practice  a  few  years,  and 
in  his  alma  mater  gave  only  a  theoretical  course  of  in- 
struction in, general  anaesthetics,  and  if,  upon  the  wit- 
ness stand,  he  would  have  to  state  that,  prior  to  engag- 
ing in  practice,  he  had  never  administered  an  ana:'s- 
thetic,  he  might  be  placed  in  a  very  compromising 
position.  Such  a  dentist  should,  for  his  own  protection, 
go  to  an  anaesthetist  of  recognized  ability  and  take 
practical  instruction  in  administering  anaesthetics.  As 
medical  and  dental  colleges  do  not  provide  such  instruc- 
tion, there  is  no  other  alternative.  This  would  apply 
equally  to  the  middle-aged  man,  or,  in  fact,  to  any 
dental  practitioner  who  desires  to  avail  himself  of  the 
use  of  anaesthetics  in  his  practice,  if  he  has  not  Jiad 
previous  practical  experience.  He  owes  this  much,  not 
only  to  himself,  but  to  the  community  in  which  he 
lives,  and  to  those  who  place  their  lives  in  his  keepmg. 

In  case  of  an  accident,  inquiry  will  also  be  made  as 
to  what  antidotes  and  restoratives  were  at  command 
when  needed,  what  measures  of  resuscitation  were 
used;  so  it  behooves  a  dental  practitioner  to  keep  him- 
self well  informed  and  abreast  of  the  times,  if  he 
administers  anaesthetics. 

A  dentist  has  a  right  to  administer  general  anais- 
thetics  in  his  practice,  unless  there  in  a  statute  to  the 
contrary;  provided,  as  previously  stated,  he  can  show 
that  he  is  competent  and  possesses  the  requisite  skill, 
knowledge  and  experience.  Davy  Crocket  used  to  say, 
"Be  sure  you  are  right,  then  go  ahead."  This  is  appli- 
cable to  the  ])rcsent  case.     Properly  prepare  yourself 


General  Ancesthetics  in  Dentistry.  19 

to  give  anaesthetics ;  have  a  good  working  knov/ledge 
of  the  physiology  of  the  lungs,  heart  and  kidneys ;  study 
the  anatomy  of  the  nerves  that  control  circulation  and 
respiration  ;  make  yourself  at  home  with  the  various 
methods  of  artificial  respiration ;  then  go  ahead  fear- 
lessly, calmly,  knowing  that  you  will  be  ready  in  any 
emergency,  and,  in  case  of  an  accident,  you  will  be 
ready  to  face  the  highest  court  of  all,  your  own  con- 
science. 

The  question  often  arises :  Would  the  dentist  be 
held  liable  for  the  consequences,  if  a  death  should  occur 
while  he  is  administering  anr  anaesthetic,  or  as  the  re- 
sult of  an  anaesthetic  administered  by  him?  The  an- 
swer turns  on  the  right  of  the  dentist  to  administer  the 
anaesthetic.  The  test,  in  each  instance,  is.  whether,  or 
not,  the  dentist  has  used  such  care  and  skill  in  the  ad- 
ministration of  the  anaesthetic  as  would  be  exercised 
by  the  average  dentist,  practicing  in  the  same  locality. 
If  the  work  that  is  undertaken  is  within  the  scope  of 
the  dentist's  practice,  and  the  substance  administered  is 
one  which  has  been  given  a  reasonable  test,  and  if 
proper  diligence  and  skill*  are  brought  to  the  treatment 
of  the  case,  the  dentist  would  not  be  held  liable  for  a 
death  which  might  result. 

Neither  a  dentist  or  a  physician  has  any  right  to 
experiment  with  new  appliances  or  anaesthetics  whicii 
have  not  been  properly  tested.  Nor  would  a  dentist 
have  a  right  to  use  an  anaesthetic  unless  familiar  with 
its  effects,  and  was  competent  to  administer  it.  I  am 
presuming  that  this  is  a  part  of  the  course  of  study  in 
e\-er\-  mc^dern  dental  college,  and  that  the  dentist  must 


20  General  Anaesthetics  in  Dentistry. 

show  his  proficiency  in  this  respect  before  he  is  ad- 
mitted to  practice  in  his  State. 

It  has  been  held  that  "where  a  person,  who  had  a 
few  days  previously  received  a  severe  blow  on  the  head, 
called  upon  a  dentist  for  the  purpose  of  having  some 
teeth  extracted,  and  which  were  extracted  by  the  den- 
tist after  the  administration  of  chloroform,  the  dentist 
was  not  liable  for  a  total  stroke  of  paralysis  which  re- 
sulted a  few  days  after,  the  court  being  of  the  opinion 
that  the  dentist  could  not  be  held  liable  for  conse- 
quences that  he  could  not  reasonably  foresee,  and  which 
were  not  the  ordinary  or  probable  result  of  what  he 
did."  (Bogle  vs.  Winslow,  5  Phil.  Pa.,  136.) 

It  has  also  been  held  that  a  dentist  is  not  held  to 
insure  the  result  of  his  work,  nor  is  he  responsible  for 
a  mistake  of  judgment  where  he  exercises  reasonable 
skill  and  care.  (Wilkens  vs.  Ferrell,  10  Tex.  civ.  app., 
231.) 


General  Ancestheiics  in  Dentistry.  21 


LECTURE  II. 

The  Value  of  General  Anaesthetics  to  the  Dental 
Surgeon. 

Anaesthetics  have  dignified  medicine ;  anaesthetics 
have  made  surgery.  Anaesthetics  can  do  nearly,  if  not 
quite,  as  much  for  the  dental  surgeon  if  he  would  avail 
himself  of  their  kind  offices.  The  general  surgeon  ad- 
ministers an  anaesthetic,  primarily,  to  prevent  pain  and 
avoid  shock;  secondarily,  to  facilitate  operating.  In 
some  cases,  the  patient  could  undergo  the  operation 
without  an  anaesthetic,  just  as  the  dental  surgeon  com- 
pels his  patients  to  undergo  the  severest  pain  in  his 
chair.  The  general  surgeon  administers  anaesthetics 
to  prevent  shock,  for  it  is  shock,  surgical  shock,  that 
kills. 

Prior  to  the  general  use  of  anaesthetics,  deaths  were 
frequent  in  simple  arm  and  leg  amputations,  while  now, 
vmder  ana3sthesia,  one  seldom  hears  of  a  death  during 
these  operations.  It  was  shock  that  killed  them.  Thou- 
sands of  brave  soldiers  in  the  Civil  War,  wounded 
by  the  enemy,  died  on  the  field  of  battle  before  medical 
assistance  could  reach  them,  not  from  hemorrhage,  not 
because  a  vital  part  was  entered  by  bullet  or  shell,  but 
from  shock,  the  result  of  intense  pain  of  long  duration. 
Anaesthetics,  then    are  used  primarily  to  prevent  pain 


22  General  Ancesthetics  in  Dentistry. 

and  to  avoid  shock.  In  this  enlightened  age  no  surgeon, 
except  the  dental  surgeon,  permits  a  patient  to  undergo, 
without  an  anaesthetic,  tortures  equal  in  severity  and 
duration  what  one  submits  to  during  the  average  dental 
operation.  Through  apprehension  that  the  instrument 
may  slip  and  enter  the  soft  tissues,  or  fear  that  a  bur 
may  accidentally  plunge  into  a  live  plup,  patients  are 
subjected  not  only  to  physical  pain,  but  to  mental  suf- 
fering as  well.  Thus,  the  nervous  system  is  at  its  high- 
est tension,  and  the  patient  often  leaves  the  chair 
fatigued,  exhausted,  sometimes  bordering  on  a  state 
of  collapse,  and  at  each  subsequent  sitting  the  strain  is 
greater.  That  is  not  all.  Upon  retiring,  the  nerves  take 
up  the  impression  made  upon  them,  and  all  night  long 
the  dental  bur  is  whirling  at  lightning  speed ;  the 
corundum-wheel  is  grinding  sensitive  dentine ;  the 
sandpaper  strip  is  drawn  rapidly  between  the  teeth, 
setting  them  on  fire,  as  it  were,  and  there  is  no  rest 
even  in  the  quiet  of  the  night. 

Exhaustion  of  the  vaso-motor  centers,  rather  than 
structural  lesions,  is  what  produces  shock,  and  I  want 
to  emphasize  the  fact  that  it  is  a  dangerous  procedure 
to  submit  even  the  physically  strong  to  intense  pain  be- 
yond certain  limits.  Under  the  benign  influence  of 
anaesthesia,  physical  suffering  is  prevented,  mental 
torture  is  obviated,  and  the  patient  steps  from  the  chair 
without  fatigue,  and  an  otherwise  restless  night  be- 
comes one  of  sweet  repose  and  refreshment.  If  we  only 
knew,  if  there  was  any  way  to  ascertain  just  how  much 
the  dental  surgeon  contributes  to  the  sum  total  of  the 
nciirasthcnia  which  is  so  prevalent  at  the  present  time, 


General  Ancestheiics  in  Dentistry.  23 

it  would  be  interesting,  but  "where  ignorance  is  bliss, 
'tis  folly  to  be  wise." 

We  are  all  familiar  with  such  expressions  as,  "It 
used  to  be  that  I  did  not  mind  having  teeth  filled,  but 
the  very  thought  of  it  now  gives  me  a  nervous  chill ;  I 
have  no  nerve  any  more" ;  "I  had  rather  die  than  have 
this  tooth  out,  and  I  hoped  that  I  would  before  it  was 
necessary  to  have  another  extracted" ;  "1  have  never 
recovered  from  the  last  time  when  I  had  several  out 
without  taking  anything" ;  and  kindred  remarks.  The 
nervous  system  has  been  impaired  by  previous  opera- 
tions, and  the  old  impressions  of  suffering  and  exhaus- 
tion are  awakened  at  the  very  thoughts  of  taking  the 
dental  chair. 

Bold  in  other  directions,  commendably  progressive 
in  all  that  relates  to  manipulative  ability  and  artistic 
development,  the  dental  surgeon  shrinks  from  anaes- 
thetics. He  cuts  into  living  tissue,  lacerating  the 
nerves  themselves,  "performing  laparotomies  upon  the 
teeth,"  so  to  speak,  and  the  ana?sthetic  usually  em- 
ployed is  that  of  witty  speech,  or  an  amusing  story, 
while  the  patient  suffers,  cringes,  agonizes  almost  to 
the  state  of  collapse. 

The  dental  surgeon  does  not  seem  to  realize  the 
extent  to  which  the  nervous  system  is  impaired  as  the 
result  of  operations  on  the  teeth.  After  prolonged 
operations  the  neurons  become  exhausted  and  there  is 
a  condition  which  I  denominate  dental  fatigue,  border- 
ing on  collapse  or  shock.  \Mien  a  patient  returns  to 
the  ofiice  and  remarks  that  she  was  completely  used  up, 
after   the    last    sitting,    the    dentist    makes   light   of    it. 


24  General  Ancesthetics  in  Dentistry. 

laughs  it  off,  adjusts  the  rubber  dam  and  begins 
the  nerve-racking  procedure  for  another  hour  or  two. 
Fortunately,  I  have  been  almost  immune  from  dental 
caries  and  have  spent  but  few  hours  in  the  dental  chair 
in  a  life-time,  and  my  case  is  hardly  a  fair  example 
of  that  dental  fatigue  which  results  from  painful  opera- 
tions, or  operations  of  long  duration,  even  though  not 
very  painful.  However,  I  had  one  experience  when  a 
dental  student  in  college  that  I  have  never  forgotten. 
The  professor  of  operative  dentistry  built  up  with  gold 
an  impaired  lower  molar  for  me.  The  sitting  was  from 
ten  o'clock  until  one.  I  had  expected  to  operate  that 
afternoon  at  the  clinic,  but  so  exhausted,  so  fatigued 
w-as  I  at  the  conclusion  of  the  operation  that  T  went 
to  my  room  and  remained  there  in  bed  from  one  o'clock 
Saturday  until  Monday  morning.  Ten  years  elapsed 
before  it  was  necessary  to  again  become  a  patient. 
This  time  caries  had  so  nearly  approached  the  pulp  in 
an  upper  bicuspid  that  it  was  necessary  to  expose  ^ind 
devitalize  the  formative  organ  of  the  tooth.  Thousands 
of  times  had  I  sent  patients  to  their  homes  with  an 
arsenical  application  on  or  in  close  proximity  to  the 
pulp,  but  not  until  I  experienced  that  little  1-100  of  a 
grain  of  arsenicus  acid,  smothered  in  sulphate  of  riior- 
phia  and  cocaine,  did  I  realize  the  weight  of  woe  that 
I  had  unsuspectingly  contributed  to  suffering  humanity. 
That  dose  laid  me  up  for  a  day  and  a  half.  When  I 
contemplate  those  more  unfortunate  patients  where  the 
operations  on  their  teeth  require  two  or  three  sittings 
a  week  for  a  period  of  several  weeks,  and  others  who 
find   it  necessary  to  visit  a  dental   surgeon  every  six 


General  Ancesthetics  in  Dentistry.  25 

months  for  professional  services,  I  am  satisfied  that 
more  humanitarian  methods  should  be  adopted.  The 
dentist  should  take  into  consideration  the  physical 
well-being  of  his  patients  and  adopt  those  methods 
which  are  the  least  destructive  of  nerve  force  and 
vitality. 

The  general  surgeon  employs  anaesthetics,  secon- 
darily, to  facilitate  operating.  Imagine,  if  you  can, 
that,  on  awakening  on  the  morrow,  the  knowledge  of  all 
ansesthetics  was  lost  to  man,  and  that  their  formulai  or 
component  parts  were  blotted  out  from  memory.  Pic- 
ture surgeons,  Samson-like,  shorn  of  their  strength, 
as  they  watch  patients  and  nurses  assemble  at  the 
various  hospitals.  Where  is  the  surgeon  who  could 
operate  successfully  under  those  conditions?  Without 
anaesthetics,  the  occupation  of  the  surgeon  would  be 
gone  and  the  hospitals  would  have  to  be  converted 
into  sanitariums  and  asylums,  where  suffering  human- 
ity must  wear  itself  out  in  pain  and  misery. 

General  ansesthetics  in  dentistry  can  be  made  to  play 
a  double  part — save  the  patient  from  suffering  and 
nerve  strain,  and  relieve  the  operator  of  the  debilitating 
influences  incident  to  controlling  patients,  highly  ner- 
vous and  hysterical,  who  sap  his  energy,  absorb  his 
vitality,  arid  deplete  his  mentality. 

Some  ten  years  ago,  in  Chicago,  while  visiting  the 
office  of  a  dentist  who  has  since  become  a  warm  pro- 
fessional friend,  I  beheld  that  which  impressed  me 
deeply.  Although  for  ten  years  previously  I  had  been 
interested  in  anaesthetics  and  gave  the  subject  as  much 
time  and  attention   as  a  busy  practitioner  could  well 


26  General  AncEsthetics  in  Dentistry. 

bestow  upon  it,  it  was  not  until  the  summer  of  1891 
that  I  fully  awakened  to  the  possibilities  of  general 
knsesthetics  in  dentistry. 

In  this  office  were  two  chairs,  each  presided  over 
by  a  lady  assistant.  Upon  completing  an  operation  the 
chair  was  vacated  and  another  patient  called,  the  opera- 
tor passing  quietly  from  one  chair  to  another.  This 
dental  surgeon  refused  to  operate  for  anyone  who 
would  not  inhale  a  general  anaesthetic,  and  he  informed 
me  that  he  averaged  at  least  twenty  administrations 
a  day.  He  maintained  that  under  chloroform  analgesia 
the  patient  was  saved  the  suffering  and  shock  incident 
to  such  operations  without  anaesthetics ;  that  he  was 
enabled  to  make  a  more  thorough  cavity  preparation, 
and  he  could  accomplish  in  a  few  minutes,  under  anaes- 
thesia, results  which  would  require  a  long  sitting  with- 
out the  aid  of  an  anaesthetic.  Although  he  was  a  man 
well  advanced  in  years,  three  score  years  and  ten,  he 
said  that  he  was  enabled  to  accomplish  this  amount  of 
work  only  because  it  dkl  not  tire  him  to  operate  when 
he  could  proceed  with  as  much  assurance  as  though  he 
was  operating  on  an  inanimate  substance. 

I  recall  an  operation  that  greatly  interested  me.  A 
young  lady  presented  with  pyorrhoea.  One  central 
incisor  had  elongated  fully  a  c[uarter  of  an  inch  ;  indeed, 
when  the  lips  were  closed  naturally,  the  tooth  projected 
s6  as  to  be  seen.  He  said  to  me  :  "What  would  you  do 
in  this  case?"  I  replied  in  jest:  "Take  a  hammer  and 
drive  it  back  on  a  line  with  the  other  teeth."  He  re- 
plied: "That  is  just  exactly  what  I  will  do."  He  ad- 
ministered chloroform,  extracted  the  tooth,  enlarged  '."he 


General  Ancesthetics  in  Dentistry.  27 

alveolar  socket,  removed  the  pulp  from  the  tooth,  filled 
the  root  canal,  placed  the  tooth  in  its  socket,  drove  it  to 
place  with  a  hammer,  made  a  splint  and  adjusted  it,  and 
the  time  consumed,  from  the  first  inhalation  of  cliloro- 
form  until  the  patient  left  the  chair,  was  just  eleven 
minutes.  Without  his  knowledge,  I  had  timed  this 
operation,  and  he  operated  and  talked  and  explained  as 
one  does  at  a  clinic,  showing"  no  haste. 

In  those  cases  where  caries  approached  the  pulp  to 
such  close  proximity  as  to  render  inflammation  and 
death  of  the  pulp  liable  as  the  result  of  a  filling,  it  was 
the  custom  of  this  dentist  to  administer  chloroform, 
open  into  the  pulp  canal  and  amputate  the  Inilbous  or 
crow^n  portion  of  the  pulp  with  a  large  bur.  Upon  the 
:cessation  of  hemorrhage  he  burnished  gold  foil  over  the 
stump,  leaving  the  root  portion  alive,  filled  with  cement, 
and  in  the  course  of  two  or  three  months  completed  the 
operation. 

I  saw  him  operate  on  several  of  these  cases  and  the 
patients  assured  me  that  they  experienced  no  pain.  I 
also  saw  cases  which  had  been  operated  on  for  pulp  am- 
putation months  previously  and  the  teeth  showed  no 
.signs  of  discoloration,  and  they  responded  to  heat  and 
cold,  showing  that  the  pulps  were  alive,  maintaining" 
the  natural  color  of  the  teeth  and  preventing  the  forma- 
tion of  alveolar  abscess. 

Attention  had  been  called  to  the  fact  that  Dr.  A.  C. 
Hewett,  of  Chicago,  for  it  was  he  to  whom  I  refer,  was 
operating  on  teeth  under  chloroform,  and  he  had  deliv- 
ered addresses  on  two  occasions  before  the  Iowa  State 
Dental  Societ}'.     So  imprcssctl  was  this  societx'  with  the 


28  General  Ancesthetics  in  Dentistry. 

claims  made  by  this  speaker,  tiiat  a  committee  was  ap- 
pointed to  go  to  Chicago  and  investigate  his  work.  I 
was  fortunate  in  being  made  a  member  of  that  com- 
mittee and  wrote  the  report  which  was  published  in 
full  in  the  proceedings  of  the  Society  for  the  year  1892. 

During  the  three  days  spent  with  Dr.  Hewett  on 
this  occasion,  the  committee  witnessed  almost  every 
operation  common  to  dentistry,  and  not  in  a  single 
case  operated  on  was  there  an  alarming  symptom,  nor 
was  there  nausea  or  delay  of  any  kind  incident  to  the 
anaesthetic. 

Here  was  food  for  thought;  here  was  something 
worthy  of  taking  home;  here  was  something  worth 
putting  to  the  test.  Beginning  at  first  with  favor- 
able cases,  I  found  in  a  few  weeks  that  chloroform 
worked  as  happily  for  me  as  for  Dr.  Hewitt. 

This  was  a  glimpse  of  the  promised  land,  a  boon 
alike  to  both  dentist  and  patient.  Each  year  the  con- 
viction that  the  dentist  should  become  proficient  in  ad- 
ministering anaesthetics  and  should  employ  them  in  hia 
daily  practice,  has  steadily  grown. 

General  anaesthetics  in  dentistry  are  valuable  to  the 
dental  surgeon  and  should  be  used  for  the  following 
reasons : 

First:  To  prevent  pain,  thus  eliminating  fatigue, 
collapse  and  shock. 

Second :  Short  sittings  are  made  possible,  which  is 
beneficial  to  both  dentist  and  patient. 

Third :  Enables  the  operator  to  do  more  thoroughly 
the  operation  to  be  performed. 


General  Ancesfhetics  in  Dentistry.  29 

Fourth:  Enables  the  operator  to  accomplish  an  in- 
creased amount  of  work  in  a  day. 

Fifth :  Dignifies  dentistry,  elevating  it  to  the  plane 
of  surgery,  and  augments  the  receipts  of  practice. 

It  is  true  that  much  of  the  supposed  hurt  is  imagin- 
ary, purely  mental,  but  that  fact  does  not  make  it  any 
easier  for  patients.  It  is  real  to  them,  and  even  the 
anticipation  of  being  hurt  disturbs  the  equilibrium  of 
the  nervous  system.  In  many  cases,  the  vibrations  re- 
sulting- from  the  contact  of  the  bur  with  dentine  or 
enamel  even  where  there  is  no  pain,  are  sufficient  to  un- 
nerve the  patient  during  the  entire  operation;  It  is 
this  strain  that  terminates  in  fatigue.  Anjesthetics  are 
of  inestimable  value  to  this  class  of  patients.  It  is 
worth  while  to  employ  anaesthetics  in  these,  if  in  no 
other  cases,  for  these  patients  consume  the  greater  por- 
tion of  the  operator's  time  as  well  as  his  strength. 
How  often  do  you  feel  completely  exhausted  after  per- 
forming some  simple  operation  for  a  nervous,  hysterical 
patient,  and  almost  wish  that  they  would  never  present 
themselves  again  for  an  operation.  Anaesthetize  them, 
give  them  the  bliss  of  anresthetic  relaxation,  if  not  of 
unconsciousness,  and  they  will  prove  to  be  quite  model 
patients. 

General  anaesthetics  can  be  employed  to  advantage 
in  the  following  cases : 

1.  Adjusting  the  rubber  dam  where  cavities  of 
decay  are  to  be  excavated  along  the  gingival  margin 
and  a  servical  clamp  employed  to  hold  the  dam  in  po- 
sition. 

2.  Cavity  preparation  for  fillings  and  inlays. 


30  General  Ancesthetics  in  Dentistry.  . 

5.       Removing  fillings  in  cases  of  pulpitis, 
tions. 

4.  Exposing  live  pulps  and  immediate  removal  of 
the  same. 

5.  Removing  fillings  in  case  of  pulpitis. 

6.  Opening  into  teeth  in  cases  of  acute  perice- 
mentitis or  acute  alveolar  abscess. 

7.  Instrumentation  and  application  of  caustics  in 
pyorrhoea. 

9.  Lancing  abscesses. 

10.  Extracting  teeth. 

11.  Other  painful  operations,  and  operations  the 
nature  of  which  produce  dental  fatigue. 

12.  Oral  surgical  operations  such  as  cleft  palate, 
hare  lip,  empyemia  of  antrum,  impacted  third  molars, 
dentigerous  cysts,  odema  and  elongation  of  uvula,  ad- 
enoid vegetations,  alveolar  and  maxillary  necrosis  and 
various  tumor  formations  in  and  about  the  mouth. 


General  AruEsthetics  in  Dentistry.  31 


LECTURE  III. 
To  Whom  it  is  Safe  to  Administer  an  Anaesthetic. 

Having-  shown  that  the  properly  qualified  dental 
practitioner  has  the  right  to  administer  general  anjes- 
thetics  in  his  daily  work  and  pointed  out  the  possibili- 
ties and  advantages  of  operating  on  patients  during 
aneesthesia,  the  question  naturally  arises,  to  whom 
is  it  safe  to  administer  an  anaesthetic?  There  is  a  mis- 
taken idea  on  the  part  of  both  the  profession  and  the 
laity  as  to  whom  it  is  safe  to  administer  anaesthetics. 
A  wide-spread  impression  prevails  that  if  the  heart  is 
sound  there  can  be  no  risk,  "whereas  in  about  ninety 
per  cent,  of  the  facilities  from  chloroform,  at  the  post- 
mortem examination,  the  heart  is  found  to  be  perfectly 
normal."  (Luke.) 

Dr.  Ochner,  in  the  last  edition  of  his  "Clinical  Sur- 
gery," says :  "In  my  experience,  patients  suffering 
from  organic  heart  lesions  have  never  had  any  serious 
or  alarming  difficulty  during  the  administration  of  an- 
aesthetics, which  is  not  true  of  patients  whose  hearts, 
lungs  and  kidneys  were  evidently  normal." 

"It  is  a  remarkable  fact  that  an  individual  whose 
health  has  become  impaired  by  disease  is  often  a  bet- 
ter subject  for  an  anaesthetic  than  one  who  enjoys  ro- 
bust health.     Although  his  heart  and  lungs  mav  be  in 


32  General  Ancesthetics  in  Dentistry. 

excellent  condition  and  able  to  stand  almost  any  strain, 
yet  he  will  not  pass  so  easily  into  anjesthetic  sleep  as  a 
less  robust  patient,  owing  to  the  more  frequent  occur- 
rence of  struggling-  excitement  which  will  interfere 
with  the  respiratory  rhythm."  (Luke.) 

Richardson  thinks  "the  bad  effects  of  anaesthesia 
are  largely  due  to  over-confidence  and  non-experience 
of  administration."  He  has  never  seen  a  death  from 
ether  itself,  and  he  thinks  that  while  there  may  have 
been  some,  the  number  is  extremely  small.  Only  urin- 
ary suppression  and  pneumonia  seem  to  him  important. 
Where  a  patient  dies  after  a  severe  operation  even  with 
these  symptoms,  it  is  an  unwarrantable  assumption 
that  death  was  due  to  the  anaesthetic  and  not  the  opera- 
tion. 

Accidents  from  the  sub-cutaneous  or  hypodermic 
use  of  cocaine  would  be  much  more  perilous  than  ether 
accidents;  the  former  would  be  caused  by  the  intrinsic 
danger  of  the  drug,  the  latter  from  disregard  of  danger 
signals,  or  over-etherization. 

Heart  disease  is  usually  regarded  as  a  contra-indi- 
cation  to  general  anaesthesia,  but  that  is  not  according 
to  his  experience.  His  chief  anxiety  has  been  from  dis- 
eases of  the  lungs;  but  he  is  inclined  to  think  that  his 
anxiety  is  seldom  justified  by  facts.  Failure  to  breathe 
is  a  serious  matter,  and  it  is  fortunate — and  in  this  fact 
lies  the  great  safety  of  ether — that  a  patient  with 
healthy  lungs,  at  least,  always  reacts  to  artificial  res- 
piration. 

As  a  rule,  simple  weakness  does  not  contra-indicate 
auc'esthesia.    Of  the  two  classes  of  patients — the  strong. 


General  Anczsthetics  in  Dentistry.  33 

robust,  full-blooded  with  bounding  pulse,  and  the  frail, 
delicate,  weak,  even  those  that  might  be  denominated 
invalids,  I  much  prefer  the  latter  for  anaesthesia.  About 
half  of  those  who  come  to  me  to  be  ancesthetized  com- 
plain of  heart  trouble,  and  these  are  the  patients  that 
cause  me  the  least  anxiety.  Many  volunteer  the  state- 
ment that  their  physician  has  warned  them  never  to 
take  an  anaesthetic — these  prove  good  subjects,  also. 
But  those  patients  who  take  the  chair  saying,  "My 
heart  is  sound,  my  lungs  are  all  right,  you  better  get 
some  one  to  help  hold  me  or  I  may  make  you  trouble" 
— patients  with  strong  physiques  and  active  brains — 
these  are  the  cases  that  require  the  greatest  care  and 
skill  in  administering  anaesthetics. 

An  experience  of  twenty-five  years  with  the  more 
commonly  used  general  anaesthetics  has  convinced  me 
that  the  heart  is  rarely,  if  ever,  primarily  affected. 

I  have  seldom  administered  ether  or  chloroform  for 
a  major  surgical  operation,  that,  at  some  stage  of  tiie 
an?esthesia,  the  patient  did  not  momentarilv  cease 
breathing  (nothing  serious),  but  never  have  I  known 
the  heart  to  cease  beating  or  Avitnessed  a  fatality. 

I  am  strongly  of  the  opinion  that  general  anaes- 
thetics cause  the  respiration  to  fail  before  the  heart  be- 
comes affected,  and  we  all  recognize  the  fact  that  it 
is  much  easier  to  re-establish  breathing  than  to  re- 
establish the  circulation.  There  is  no  higher  authority 
on  this  subject  than  T.  Lauder  P.runton.  chairnian  of 
the  Hyderabad  Commission,  who  s:iys  :  "So  far  as  the 
anaesthetic  is  concerned,  in  99,999  out  of  100,000  cases 
it   causes  the  respiration   to   fail  before   it   affects  the 


34  General  Ancesthettcs  in  Dentistry. 

heart,  and  if  you  attend  to  the  respiration  carefully  I 
do  not  believe  you  run  very  much  risk  of  the  heart. 
But  remember  that  I  make  this  statement  only  in  re- 
gard to  the  anaesthetic,  for  shock  may  have  a  different 
effect." 

We  have  been  taught  or  impressed  by  the  litera- 
ture extant  on  anaesthetics  that  it  is  safe  to  administer 
ether  if  the  lungs  are  sound,  and  safe  and  proper  to 
administer  chloroform  when  the  heart  is  normal.  If 
this  were  true,  it  would  simplify  the  matter  of  select- 
ing the  proper  anesthetic  each  time  for  a  given  case, 
but  unfortunately  the  human  race  is  not  divided  into 
two  classes,  one  with  sound  hearts  and  the  other  with 
sound  lungs.  Luke  claims  that  in  ninety  per  cent,  of 
the  deaths  occurring  during  chloroform  anaesthesia  the 
heart  was  perfectly  normal.  As  to  the  number  of  fatal- 
ities of  those  possessing  sound  lungs  under  ether  anaes- 
thesia, I  have  no  statistics  at  hand,  but  I  doubt  not  the 
percentage  would  be  as  high,  for  I  am  satisfied  that  in 
neither  case  is  the  ether  or  chloroform  per  se  respon- 
sible for  these  deaths. 

It  is  impressive  to  state  that  in  the  case  of  sound 
lungs  administer  ether,  and  in  the  case  of  normal 
heart  administer  chloroform ;  but  you  will  frequently 
find  in  the  same  patient  an  impaired  heart,  a  tubercu- 
lar lung,  a  diseased  kidney,  a  shattered  nervous  sys- 
tem, yet  an  anaesthetic  must  be  administered  because  of 
some  gynaecological  complication  or  an  inflamed  ap- 
pendix. A  well-known  writer  on  anaesthesia  says :  "You 
must  not  administer  ether  in  bronchitis  or  inflamma- 
tory conditions  of  the  pulmonary  tract,  in  acute  chronic 


General  Ancesihetics  in  Dentistry.  35 

nephritis,  aneurism,  atheroma,  endocarditis,  and  high- 
tension  pulse,  in  operations  on  the  brain,  in  operations 
on  the  pelvic  cavity,  because  it  does  not  as  thoroughly" 
relax  as  chloroform,  or  to  those  addicted  to  alcohol 
or  narcotics." 

"Chloroform  is  contra-indicated  in  empyemia  with 
dilatation  of  the  right  side  of  the  heart,  fatty  degener- 
ation of  the  heart  muscles,  dilatation  of  the  heart  with 
corresponding  hypertrophy,  in  extreme  prostration,  in. 
aenemia  or  shock,  collapse,  hemorrhage,  ver}^  stout 
subjects,"  etc.,  etc. 

Indeed,  it  would  require  a  page  to  enumerate  the 
conditions  contra-indicating  anaesthetics;  5^et  thousands 
of  operations  are  performed  daily  for  patients  having 
one  or  more  of  these  conditions  and  a  mortality  rarely 
occurs.  In  some  hospitals  ether  is  used  almost  exclu- 
sively, in  others  chloroform.  The  matter  of  prefer- 
ence is  confined  not  only  to  hospitals,  but  to  sections 
of  the  country  where  one  anaesthetic  or  the  other  will 
be  used  almost  invariably  independent  of  the  physical 
condition  of  the  patient.  One  would  naturally  sup- 
pose that  a  patient  having  several  of  the  conditions 
named  could  not  safely  take  a  general  anaesthetic;  but 
no  surgeon  refuses  to  operate  for  these  cases,  yet 
deaths  are  so  rare  under  anaesthetics  that  many  prom- 
inent surgeons  have  never  witnessed  a  mortality. 

To  whom  it  is  safe  to  administer  an  anaesthetic  be- 
comes a  perplexing  question  when  the  strong,  the 
healthy,  the  robust  are  more  liable  to  accidents  than 
the  weak,  the  frail  and  the  patient  in  poor  health;  when 
eminent    surgeons    find    that    patients    with    impaired 


36  General  Ancesihetics  in  Dentistry. 

hearts,  kidneys  and  lungs  are  safe,  while  those  whose 
vital  organs  are  in  a  state  of  health  are  liable  to  acci- 
dents. Further,  notwithstanding  a  long  list  of  patho- 
logical conditions,  any  one  of  which,  we  are  told  by 
some  authorities,  contra-indicates  a  certain  anaesthetic, 
in  the  hands  of  other  anesthetists  patients  having  these 
conditions  are  anaesthetized  every  day  without  acci- 
dents or  subsequent  trouble.  How  is  one  to  intelli- 
gently determine  to  whom  it  is  safe  to  administer  an 
anaesthetic?  In  hospitals,  and  usually  in  private  prac- 
tice, a  careful  preliminary  examination  is  made  to  de- 
termine the  condition  of  the  heart,  lungs,  and  kidneys 
of  the  patient  to  be  anaesthetized.  This  report  is  re- 
corded on  blanks  made  for  the  purpose  and  placed  in 
the  hands  of  the  anaesthetist.  He  makes  a  study  of 
this  report  and  decides  in  advance  the  anaesthetic  to  be 
employed.  If  there  are  heart  lesions,  he  knows  it.  If 
there  are  abnormal  pulmonary  conditions,  he  is  av^^are 
of  that.  If  albuminuria  is  present,  the  examination 
has  shown  it.  The  anaesthetist  is  ready  ior  the  battle, 
knowing,  as  it  were,  in  advance,  the  weak  places  in  the 
ranks  of  the  enemy. 

It  is  said,  to^be  forewarned  is  to  be  forearmed.  In 
cases  of  pathological  lesions,  the  aniESthetist,  knowing 
in  advance  v/hat  may  happen,  is  careful  to  the  minutest 
detail  in  the  choice  and  the  method  employed  in  ad- 
ministering the  anaesthetic.  Never  for  a  moment  does 
he  take  his  attention  from  the  patient,  watching  for 
the  least  deviation  from  normal  of  the  respiration,  cir- 
culation, and  the  pupil.  This,  to  my  mind,  is  the  ex- 
])]anation  when  Dr.  Ochncr  says.  "In  my  experience, 


General  Ancesthetics  in  Dentistry.  37 

patients  suffering  from  organic  heart  lesions  have  never 
liad  any  serious  or  alarming  difficulties  during  the  ad- 
ministration of  anaesthetics,  while  this  is  nottrue  of 
patients  whose  hearts,  lungs,  and  kidneys  are  evidently 
normal."  The  vital  organs  being  pronounced  nornial, 
the  anaesthetist  is  not  so  careful  as  to  what  anaesthetic 
he  will  employ,  lie  begins  with  a  stronger  vapor,  per- 
haps, than  he  should,  and  pushes  it  along  faster  than  in 
a  less  robust  subject,  and  probably  becomes  interested 
in  the  operation  himself,  there  apparently  l^eing  no 
risk  in  regard  to  the  anaesthetic,  allows  the  patient  to 
go  down  deeper  than  necessary,  or  to  come  out  from 
under  the  iniluence  of  the  anaesthetic,  not  exercising 
that  extreme  care  and  watchfulness  he  would  if  he 
knew  his  patient  had  a  heart  lesion.  I  am  satisfied 
that  it  is  not  the  anaesthetic  that  is  primarily  responsi- 
ble for  accidents  during  anaesthesia  when  the  accident 
is  traced  to  the  anaesthetic,  but  it  is  the  fault  of  the  an- 
aesthetist who  has  not  properly  administered  the  an- 
aesthetic. 

Inexperience,  ignorance,  and  carelessness  on  the 
part  of  the  anaesthetist  are  responsible  for  more  deaths 
than  the  action  of  all  anaesthetics  combined. 

If  it  is  true,  as  Luke  says,  that,  "in  about  ninety 
per  cent,  of  the  fatalities  that  occur  during  chloroform 
anaesthesia,  the  post-mortem  shows  the  heart  to  be  per- 
fectly normal,"  if  chloroform  ^^■as  the  cause  of  the 
death,  the  tlieory  to  administer  chloroform  when  the 
heart  is  sound  is  erroneous. 

Again,  if  the  lieart  is  found  normal  in  ninciy  per 
cent,   of   chloroform   fatalities,   it   looks   as   if  the   fatal 


38  General  AncBsthetics  in  Dentistry. 

action  must  have  manifested  itself  through  some  other 
organ  than  the  heart.  It  would  hardly  be  the  kidneys, 
and,  eliminating  the  kidneys,  death  must  be  caused  by 
paralysis  of  the  respiration. 

For  years  I  have  maintained  that  respiration  was 
the  important  thing  to  watch,  long  before  I  knew  that 
Brunton  claimed  that,  in  so  far  as  the  anjesthetic  itself 
was  concerned,  in  "99,999  out  of  100,000  cases  the  res- 
piration ceased  before  the  heart's  action."  It  is  pre- 
posterous to  hold  aneesthetics  so  largely  responsible 
for  deaths  that  occur  during  anaesthesia,  and  I  shall 
show  in  another  lecture  that  only  occasionally  are 
deaths  caused  from  anaesthetics,  and  these  usually  be- 
cause the  anaesthetic  was  not  properly  administered.  I 
am  aware  of  the  fact  that  chloroform  is  a  protoplasmic 
poison  and  ether  a  nephretic  irritant;  but  the  question 
is  not  what  ether  and  chloroform  can  do  ad  libitum, 
but  what  effect  they  have  upon  'the  tissues  and  organs 
of  the  body  when  used  as  anaesthetics,  intelligently  and 
properly  administered. 

This  chapter  is  written  from  a  clinical  standpoint, 
and,  clinically,  the  most  important  thing  is  to  watch  the 
breathing.  Not  for  a  moment  should  the  attention  of 
the  anaesthetist  be  diverted  from  the  respiration.  In  the 
matter  of  observing  respiration  not  only  the  eye  but 
the  ear  can  be  trained  to  assist.  Do  not  wait  for  some- 
thing startling  to  occur,  but  the  moment  there  is  the 
least  deviation  from  the  normal  institute  measures  to 
compel  the  patient  to  breathe  properly.  "If  you  attend 
to  the  respiration  carefully,  I  do  not  believe  that  you 
run  very  much  risk  of  the  heart.     This  statement  re- 


General  Ancesthetics  in  Dentistry.  39 

fers  strictly  to  the  anesthetic,  for  shock  may  have  a 
different  effect."     (Brunton.) 

From  my  standpoint,  then,  the  question  to  whom 
is  it  safe  to  administer  an  anaesthetic  for  dental  opera- 
tions turns  on  the  matter  of  properly  administering  the 
anaesthetic.  It  becomes  a  personal  equation.  The  an- 
assthetist  must  be  one  who  possesses  the  ability  to  in- 
spire the  patient  with  confidence,  to  allay  all  fear  as  to 
the  probable  outcome,  and  relieve  the  mind  of  all 
anxiety. 

The  psychical  element  is  one  of  the  most  potent 
with  which  we  have  to  deal.  Timidity  and  nervous- 
ness on  the  part  of  the  one  who  is  to  administer  the 
anaesthetic  is  communicated  to  the  patient,  and  un- 
nerves him  for  the  ordeal.  You  can  not  administer 
anaesthetics  successfully  unless  you  have  confidence  in 
both  yourself  and  the  anaesthetic  and  understand  ho^^' 
to  administer  them. 

I  had  rather  take  my  chances  on  anaesthetizing  a 
patient  with  valvular  lesion  of  the  heart,  a  morbid  kid- 
ney, and  an  impaired  lung,  mind  tranquil,  than  to  an- 
aesthetize a  patient  who  takes  the  chair  white  with 
fear,  gasping  with  short  quick  breaths,  circulation  "oft'," 
with  normal  heart,  lungs  and  kidneys.  As  I  look  back 
over  an  angesthetic  career  of  twenty-five  years  I  can 
recall  only  a  few  patients  to  whom  I  have  refused  to 
administer  an  anaesthetic  and  the  contra-indication  in 
each  case  has  usually  been  the  psychical  condition  of 
the  patient. 


General  Anaesthetics  in  Denlistfy. 


LECTURE  IV. 

Elements  of  Danger. 

The  elements  of  danger  surrounding  the  adminis- 
tration  of   general   angesthetics   may   be    classified   as 
follows : 
First:       Ignorance,  inexperience,  and  carelessness  on 

the  part  of  the  anaesthetist. 
Second :  Length  of  duration  of  the  anaesthesia  induced. 
Third:     Physical  condition  of  the  patient  to  be  ana^i- 

thetized. 
Fourth :  Shock. 

In  civic  matters,  ignorance  of  the  law  excuses  no 
man.  How  important  it  is  then  that  the  ana?sthetist., 
who,  for  the  time  being,  takes  the  life  of  the  patient  in^o 
his  own  keeping  and  is  responsible  for  it,  should  sur- 
round himself  with  all  the  safeguards  and  knowledge 
pertaining  to  this  subject.  One  must  familiarize  him- 
self with  the  various  ansesthetic  symptoms — to  do  less 
is  criminal.  It  will  be  shown  that  deaths  during  anaes- 
thesia are  the  result,  in  nearly  all  cases,  of  operating 
too  soon,  before  the  patient  is  properly  anesthetized  ; 
or  operating  too  long,  while  the  patient  is  coming  out 
of  the  anaesthetic ;  or  the  anaesthesia  induced  is  not  suf- 
ficiently profound  to  avoid  shock,  hence  the  paramount 
importance  of  knowing  anaesthetic  symptoms.       Igno- 


General  Anecstheiics  tn  Dentistry.  41 

ranee  in  these  matters  has  resulted  in  sending  thou- 
sands of  patients  to  unnecessary  graves. 

Medical  and  dental  colleges  are  at  serious  fault  in 
that  they  do  not  compel  their  students  to  administer 
anaesthetics  frequently,  in  the  presence  of  competent  in- 
structors. It  has  been  said  that  "The  student  can 
learn  to  administer  anaesthetics  after  leaving  school." 
The  same  could  be  said  of  the  porcelain  inlay  or  the 
gold  filling.  The  general  public  expect  graduate  den- 
tists to  do  well  what  they  undertake  to  do,  but,  in  the 
matter  of  general  anaesthetics,  the  dental  surgeon  m.ust 
learn,  if  at  all,  on  his  own  patients  in  his  own  office. 
You  can  not  become  a  competent  anaesthetist  by  simply 
looking  on.  You  must  take  the  inhaler  in  your  own 
hand ;  feel  the  responsibility  of  the  patient's  life ;  test 
the  pulse  for  yourself;  watch  the  breathing  and  study 
the  pupillary  movements.  Not  knowing  the  anaesthetic 
stages,  the  tyro  becomes  alarmed  at  harmless  symp- 
toms entirely  overlooking  the  quiet  danger  signals.  He 
is  inclined  to  operate  too  soon  or  too  long,  and  thus 
makes  a  failure,  bringing  into  disrepute  some  worthy 
appHance,  and  condemns  anaesthetics  for  dental  pur- 
poses, simply  because  he  is  ignorant  of  both  the  prin- 
ciples and  practice  of  anaesthetics. 

In  January,  1905,  I  stepped  into  the  office  of  a  dent- 
al acquaintance  in  a  Colorado  city,  and  found  him  en- 
gaged in  a  boisterous  conversation  with  a  young  man, 
threatening  to  throw  him  out  of  the  window  if  he  did 
not  leave  the  room  instantly.  I  was  astonished  at  the 
temper  exhibited  and  the  language  used  by  this  usually 
mild    Christian    gentleman.      Inquiry   brought   out    the 


42  General  Ancesthetics  in  Dentistry. 

cause  of  the  disturbance.  I  learned  that  the  young-  man 
who  made  his  exit  so  hurriedly  on  my  entrance  to  the 
office  was  an  agent  demonstrating  one  of  the  newer 
anaesthetics.  Upon  assuring  the  dentist  that  the  anaes- 
thetic in  question  was  pleasant  to  take,  harmless  to  a 
certainty,  profound  enough  in  its  action  to  prevent  pain, 
and  was  followed  by  no  unpleasant  results,  he  was  per- 
mitted to  administer  it  to  a  patient  belonging  to  one  of 
the  wealthiest  and  most  aristocratic  families  of  the  town 
— one  of  the  doctor's  choicest  patients.  The  dentist 
proceeded  to  operate  when  assured  it  was  the 
proper  time.  The  patient  was  only  partially  anaesthe- 
tized. A  scene  occurred  such  as  only  those  who  have 
witnessed  the  like  can  appreciate.  Learning  the  hotel 
at  which  the  young  man  was  registered,  I  called  on  him 
and  asked  him  the  history  of  the  occurrence.  He  said 
this :  "I  am  not  a  dentist — only  a  dental  salesman. 
My  house  compels  me  to  go  from  office  to  office  and 
demonstrate  this  anaesthetic.  I  have  no  right  to  ad- 
minister an  anaesthetic,  and,  if  a  death  should  occur,  I 
know  that  I  will  be  sent  to  the  penitentiary.  I  am 
deadly  afraid  of  the  stuff,  and,  rather  than  make  a  mis- 
take and  give  too  much,  I  had  the  Doctor  operate  too 
soon,  with  the  result  you  witnessed."  Are  you  sur- 
prised that  dentists  make  failures  and  are  unal)le  to  get 
satisfactory  results,  when  all  that  many  of  them  know 
about  the  subject  is  what  they  see  at  an  occasional  clinic 
or  learn  from  some  salesman  demonstrator^  whose  sum 
total  of  knowledge  of  anaesthetics,  their  action  and 
danger,  is  usually  no  greater  than  that  of  the  man 
mentioned? 


General  Ancesthetics  in  Dentistry.  43 

Dental  colleges  are  strict  in  their  requirements  in 
regard  to  all  other  studies  in  their  curriculum,  requir- 
ing so  many  points  in  gold  fillings,  so  many  in  amal- 
gam, so  many  in  crown  and  bridge  work,  the  requisite 
number  in  orthodontia,  etc.,  but,  when  it  comes  to  an- 
aesthetics, the  only  study  in  the  course  in  which  the  life 
of  the  patient  is  involved,  they  are  satisfied  to  have 
some  one  make  an  occasional  demonstration,  the  stu- 
dents looking  on.  Dr.  C.  M.  Paden.  of  Chicago,  in  the 
American  Dental  Journal  for  October.  1906,  has  this  to 
say:  "Why  do  some  dentists  have  trouble  in  adminis- 
tering anaesthetics?  Because  students  are  graduated 
from  our  schools,  with  the  theory  only,  and  not  the 
practical  experience.  A  few  days  ago  I  had  occasion 
to  meet  one  of  the  graduates  of  1906  from  one  of  the 
schools  in  this  city.  I  asked  him  what  experience  he 
had  in  administering  anaesthetics  during  his  college 
course.  He  said  that  he  had  the  best  of  theor}',  but 
scarcely  any  experience.  'How  many  times  did  you 
administer  or  assist  the  demonstrator  with  chloroform, 
ether  or  nitrous  oxid,  or  how  many  times  did  you  see 
these  anaesthetics  administered?'  He  said:  'I  never 
assisted  or  saw  these  anaesthetics  administered.'  I 
asked  him  if  there  had  been  any  operations  performed 
under  anaesthetics.  He  said:  'Yes,  but  in  all  the  opera- 
tions that  I  witnessed  the  patient  was  anaesthetized 
before  being  brought  into  the  pit.'  'How  many  admin- 
istrations was  each  student  required  to  give  with  the 
assistance  of  the  demonstrator?'  'A  student  was  not 
allowed  to  administer  an  anaesthetic;  it  was  always 
done  by  a  demonstrator.'  " 


44  General  Anesthetics  in  Dentistry. 

Such  carelessness,  almost  criminal,  is  equalled  only 
by  our  medical  schools.  Even  in  our  best  hospitals,  in- 
ternes, selected  from  the  class  just  graduated  become 
anaesthetists  over  night,  and  assume  entire  charge  of 
the  anaesthetic  work.  It  is  a  burning  shame  that  every 
hospital  has  not  a  professional  anaesthetist,  so  that  this 
■work  may  not  be  left  to  inexperienced  men. 

Anaesthetics  in  themselves  are  not  so  dangerous  as 
the  fact  that  medical  men  are  turned  loose  on  the  public 
without  practical  experience  in  administering  anaes- 
thetics, and  dental  graduates  administer  anaesthetics 
without  even  as  much  experience  as  our  medical 
brothers.  Notwithstanding  this  condition  of  affairs, 
the  percentage  of  deaths  during  ansesthesia  is  not  high, 
and  I  will  show  in  a  later  lecture  that  a  number  of  cases 
have  been  included,  for  which  the  anassthetic  was  in 
no  way  responsible. 

Some  months  ago  I  had  a  difficult  third  molar  oper- 
ation at  one  of  the  Iowa  hospitals.  The  patient  took 
the  anaesthetic  badly;  indeed,  at  no  stage  of  the  opera- 
tion did  the  anaesthetist  succeed  in  producing  a 
profound  anaesthesia — it  seemed  impossible  even  to  ob- 
tain that  depth  of  anaesthesia  which  insures  safety  and 
comfortable  operating.  In  all  twenty-four  ounces  of 
ether  were  inhaled  and  wasted.  A  surgeon  in  an  adjoin- 
ing room  in  less  time  performed  a  hysterectomy, 
dressed  and  left  the  hospital.  About  a  month  later,  I 
went  to  a  medical  college  in  the  same  town  to  give  a 
clinic  and  met  there  a  young  man  whose  face  was  very 
familiar,  but  I  could  not  place  hiiu.  I  inquired,  "Wiiere 
have  I  met  you?"  He  replied,  "I  am  the  man  who  ad- 


General  Ancesthetics  in  Dentistry.  45 

ministered  ether  for  you  at  the  hospital  not  long  ago. 
The  iterne  was  away  on  his  vacation  and  I  was  taking 
his  place."  This  man  was  a  junior  medical  student. 
One's  blood  boils  with  indignation  when  subjected  to 
such  imposition. 

The  interne  question  is  an  important  one.  The  in- 
terne is  a  valuable  adjunct  to  the  hospital,  but  there 
should  be  a  professional  anaesthetist  at  every  hospital, 
whose  duty  should  be  to  carefully  diagnose  all  anaes- 
thetic cases  in  advance  of  the  operation  and  determine 
the  anaesthetic  to  be  employed.  The  interne  should 
work  under  and  in  conjunction  with  the  chief  anaes- 
thetist and  not  have  the  entire  responsibility  of  the 
anaesthetic  cases.  The  service  of  an  interne  is  from 
six  months  to  two  years  ;  they  are  constantly  changing; 
new  men  take  up  the  work  and  with  it  the  anaesthetic 
responsibility. 

Many  lives  have  been  sacrificed  during  anaesthesia 
because  the  anaesthetist  became  so  absorbed  in  the 
operation  as  to  neglect  the  patient.  The  tendency  and 
the  temptation  alwa3^s  is  to  watch  the  operation,  and, 
for  this  reason,  the  anesthetic  specialist  or  the  profes- 
sional anaesthetist  Avho  has  no  intention  of  becoming  a 
surgeon  or  an  operator  renders  superior  service. 

Women  make  the  best  anaesthetists.  They  naturally 
shrink  from  operative  procedure,  care  nothing  about  it, 
and  bestow  their  undivided  attention  on  the  patient. 
There  is  no  place  in  the  world  where  they -get  such 
wonderful  anaesthetic  results  as  at  the  Mayo  Clinic, 
Rochester,  Minn.,  and  the  anaesthetists  are  all  women. 
Alice  Magaw,  the  most  successful  anaesthetist  I  have 


46  General  Ancesthetics  in  Dentistry.. 

ever  known,  reigns  supreme  at  Rochester.  To  say  that 
she  has  a  record  of  more  than  1^,000  ether  anaesthesias 
without  an  accident  does  not  tell  the  whole  story.  She 
is  masterful  in  handling  patients,  and  with  an  amount 
of  anaesthetic  that  hardly  sounds  reasonable,  in  so  brief 
a  time  you  would  hardly  believe  the  statement,  tact- 
fully, skilfully  induces  anaesthesia. 

It  is  claimed  that  the  instruction  in  general  anses- 
thetics  in  dental  colleges  is  meagre  and  not  practical; 
the  same  may  be  said  of  the  medical  schools.  Unless 
the  medical  student  is  so  situated  that  he  can  take  a 
post-graduate  hospital  course,  or  become  an  interne, 
not  one  in  ten  ever  administers  an  anaesthetic  until 
after  graduation  and  entering  practice.  It  is  probably 
true  that  anaesthetics  receive  less  attention,  in  both 
medical  and  dental  colleges,  than  any  other  subject  in 
the  curriculum,  and  this  is  so,  not  only  in  this  country, 
but  abroad,  as  the  following  quotation  from  the  British 
Medical  Journal  will  show:  Dudley  W.  Buxton,  the 
renowned  English  authority  on  anaesthetics,  says,  "At 
present  there  is  no  uniform  teaching  on  anaesthetics," 
He  suggests  that  a  resolution  be  passed  by  the  general 
medical  council  compelling  all  medical  students,  before 
applying  for  final  examinations,  to  ofifer  evidence  of 
having  attended  the  practice  of  some  recognized  anaes- 
thetist. He  should  also  offer  proof  of  having  adminis- 
tered nitrous  oxid,  ether  and  chloroform."  Galloway 
calls  attention  to  the  common  carelessness  in  regard 
to  the  use  of  anaesthetics.  He  claims  that  if  unneces- 
sary deaths  occur  from  anaesthetics  the  responsibility 
extends    beyond    the    anaesthetizer    and    includes    the 


General  Ancesthetics  in  Dentistry.  47 

medical  college  which  ignores  its  importance,  makes 
no  effort  to  teach  it  properly,  if  at  all,  and  then  confers 
a  diploma  which  the  public  accepts  as  the  evidence  of 
a  training  which  the  student  really  has  not  received. 
The  criticism  is  just,  that  the  dental  colleges  are  not 
devoting  as  much  time  to  practical  ansssthesia  as  they 
should,  and  the  same  criticism  is  equally  just,  that 
medical  schools  are  almost  criminally  negligent  in  their 
carelessness  about  anaesthetics. 

I  am  confident  that  if  medical  schools  demanded 
as  thorough  a  course  of  practical  training  in  anaes- 
thetics as  they  do  in  the  dissecting-room  in  anatomy, 
in  their  laboratories  in  histology,  pathology,  and  chem- 
istry, and  if  dental  colleges  would  insist  on  an  anaes- 
thetic technic  as  they  have  done  in  operative  and  pros- 
thetic dentistry  and  orthodontia,  the  percentage  of 
deaths  could  be  reduced  fifty  per  cent,  in  ten  years' 
time. 

Length  of  Duration  of  Anaesthesia. 

Other  things  being  equal,  a  brief  ansesthesia  is  safer 
than  a  prolonged  ansesthesia.  The  anaesthetist  feels 
less  anxiety  when  an  anjesthesia  of  ten  minutes  is  to 
be  induced,  than  when  it  is  necessary  to  obtain  an 
anaesthesia  of  two  hours  or  more  for  the  same  patient. 
The  dental  surgeon  is  fortunate  in  that  nearly  all  the 
operations  he  is  called  upon  to  perform  are  of  brief 
duration  and  a  general  an[esthetic,  properh^  selected 
and  administered,  would  be  less  harmful  to  the  patient 
than  the  effect  of  the  pain  on  the  nervous  system 
without  an  anaesthetic. 


48  General  AncBsthetics  in  Dentistry. 

A'Vith  the  exception  of  badly  impacted  third  molars, 
antrum  cases,  cleft  palate,  resection  of  a  nerve  for 
neuralgia,  necrotic  conditions,  and  tumor  formations, 
all  of  which  really  belong  to  the  oral  surgeon,  the 
dental  surgeon  seldom  needs  a  profound  anaesthesia  of 
more  than  five  minutes'  duration  for  any  operation 
that  he  is  called  upon  to  perform. 

If  it  be  true  that  chloroform  is  a  protoplasmic 
poison,  and  ether  a  nephritic  irritant,  the  brevity  of 
anaesthesia  for  dental  operations  would  eliminate  the 
probability  of  harm  from  these  conditions,  because 
deleterious  effects  would  result  only  from  a  prolonged 
anaesthesia. 

While  brief  anaesthesia  is  not  synonymous  with 
brief  induction,  it  does  imply  brief  elimination.  The 
quicker  the  elimination  of  a  general  anassthetic  from 
from  the  system,  the  speedier  the  return  of  all 
functions  to  the  normal.  If  brief  elimination  is 
to  be  desired,  brief  induction  is  equally  to  be  de- 
sired, and  we  approach  the  ideal  anaesthetic.  In  other 
words,  the  patient  should  be  in  the  anaesthetic  state 
the  least  possible  length  of  time  for  successful  per- 
formance of  the  operation  in  question,  and  the  quicker 
the  induction,  and  quicker  the  elimination,  the  better 
for  all  parties  concerned;  provided,  of  course,  the 
anassthetic  agent  is  a  safe  one.  Herein  lies  the  safety 
and  advantage  of  nitrous  oxid  and  somnoform.  You 
can  creep  up,  as  it  were,  on  the  brain  and  nervous  sys- 
tem, anaesthetize  them,  operate,  and  the  patient  return 
to  consciousness,  almost  before  the  central  nervous 
system  realizes  that  an  anaesthetic  has  been  employed. 


General  Anaesthetics  in  Dentistry.  49 

Such  operations  as  I  have  outHned  in  the  second  lecture 
can  be  performed  under  the  influence  of  nitrous  oxid 
or  somnoform,  the  anaesthesia  gently  maintained,  not 
so  deep  as  for  extraction  of  teeth,  but  only  to  the  stage 
of  unconsciousness.  The  obtundent  or  analgesic  stage 
is  sufficient  to  allay  all  fear  on  the  part  of  the  patient 
and  prevents  that  worn-out,  all-gone  feeling  of  ex- 
haustion and  fatigue  during  and  subsequent  to  dental 
operations. 


50  General  Ancesthetics  m  Dentistry. 


LECTURE  V. 
Shock. 

The  fourth  classification  under  Elements  of  Danger 
in  that  condition  which  causes  more  deaths  during  an- 
aesthesia than  all  other  accidents  combined,  namely, 
shock.  By  shock,  we  mean  depression.  AVe  have  de- 
pression of  respiration,  or  respiratory  shock;  depres- 
sion of  the  circulation,  or  circulatory  shock.  Hewitt 
goes  further  and  adds  what  he  calls  composite  shock; 
i.  e.,  respiratory  shock  rapidly  followed  by  circulatory 
depression,  or  circulatory  shock  rapidly  followed  by 
respiratory  depression. 

It  is  difficult  to  formulate  an  intelligent,  scientific 
definition  of  shock.  Nearly  every  writer  on  this  sub- 
ject has  a  definition  of  his  own,  which  definition  does 
not  meet  the  approval  of  any  other  writer;  hence,  there 
is  a  multitude  of  definitions,  but  a  lack  of  unanimity 
of  thought,  which  is  confusing  and  unsatisfactory. 
Taking  into  consideration  the  causes  of  shock  and  com- 
bining this  with  the  manifestations  of  shock,  the  con- 
dition is  defined.  A  patient  in  a  condition  of  shock  is 
quiet ;  the  mucous  membrane  is  pale ;  the  temperature 
frequently  below  normal ;  the  pulse  rapid,  but  weak ; 
the  blood  pressure  low;  the  cutaneous  reflexes  dimin- 
ished or  abolished;  respiration  shallow;  skin  cold  and 


General  Ancesthetics  in  Dentistry.  51 

clammy;  increased  respiration;  increased  perspiration ; 
the  action  of  the  mind  slow  or  dazed;  neither  delirium 
or  hysteria  is  present ;  no  nervousness ;  pupil  some- 
what dilated  and  responds  feebly  to  light.  These  are 
the  conditions  we  find  present  in  shock  to  a  less  or 
greater  degree. 

Now  as  to  the  causes  of  shock.  The  causes  are 
numerous,  but  they  act  in. each  case  by  stimulating 
the  afferent  nerves,  and,  if  these  nerves  are  stimulated 
too  suddenly,  too  frequently,  too  painfully,  too  forcibly, 
or  in  a  too  prolonged  degree,  shock  supervenes. 

'  Shock,  then,  may  be  defined  as  a  condition  of  de- 
pression, produced  by  exhaustion  of  the  medullary 
centers  controlling  respiration  and  circulation,  by  a  too 
sudden,  too  frequent,  too  painful,  too  forcible  or  too 
prolonged  stimulation  of  the  afferent  nerves,  "the  es- 
sential phenomenon  being  a  diminution  of  the  blood 
pressure." 

For  the  sake  of  convenience,  we  may  classify  pa- 
tients suffering'  from  shock  into  two  groups : 
First :     Psychical,  those  who  are  affected  by .  mental 

impressions. 
Second :  Physical,  those  in  which  shock  is  dependent 

upon  too  sudden,  too  frequent,  too  painful, 

too  forcible,  or  too  prolonged  stimulation  of 

the  afferent  nerves. 
In  the  first  group,  the  psychical,  those  who  are 
affected  by  mental  impressions,  fear  is  the  etiological 
factor  to  be  dealt  with — fear  or  dread  of  the  operation ; 
fear  or  dread  of  the  ansesthetic,  if  one  is  suggested. 
The  dental  surgeon  meets  and  must  combat  this  con- 


52  General  Anaesthetics  in  Dentistry. 

dition  daily.  Not  long  ago,  a  patient  to  whom  I  had 
just  administered  an  anesthetic  for  an  extraction  told 
me  that  on  a  former  occasion,  while  sitting  in  a  den- 
tist's chair,  the  dread  of  having  used  a  local  anaesthetic 
was  so  terrifying,  that  before  the  dentist  had  time  to 
make  the  injection,  she  fainted  and  for  two  hours  was 
in  a  most  critical  condition.  It  was  only  the  assurance 
that  I  could  operate  absolutely  painlessly,  that  gave 
her  sufficient  confidence  to  take  the  anaesthetic. 

Dr.  McClanahan,  of  Iowa  Falls,  Iowa,  told  me  that 
he  had  a  similar  experience,  except  that  he  was  to  make 
an  examination  of  the  teeth,  not  to  extract.  He  turned 
to  his  instrument  case  a  moment,  and,  upon  resuming 
his  position  at  the  chair,  his  patient  was  pale,  gasping 
for  breath,  had  lost  consciousness,  and  it  was  three 
hours,  assisted  by  physicians,  before  she  was  resusci- 
tated. 

While  writing  the  above  sentence,  the  postman 
brought  the  mail,  leaving  a  sample  copy  of  The  D.  D. 
S.  for  September-October,  1907.  The  first  article  is 
entitled 

"Death  From  Shock. 

"Since  our  last  issue  a  Dayton  dentist  has  had  one 
of  those  experiences  that  are  so  trying  to  the  mem- 
bers of  our  profession — namely,  a  death  in  his  chair 
while  engaged  in  performing  his  regular  duties. 

"A  young  woman  applied  to  him  for  the  extraction 
of  a  tooth.  There  was  nothing  about  her  condition 
that  would  indicate  that  she  was  not  in  average  health, 
aiul  tlie  dentist  prepared  to  relieve  her  of  the  offending 
mcniljcr. 


General  Anaesthetics  in  Dentistry.  53 

"There  were  reasons  that  seemed  entirely  satis- 
factory to  him  why  a  general  anaesthetic  need  not  be 
given,  though  he  is  expert  in  the  use  of  somnoform, 
neither  was  he  prompted  to  inject  the  tissues  with  a 
local  anaesthetic.  Instead  of  these  he  saturated  a 
pledget  of  cotton  with  an  anodyne,  applied  it  over  the 
gum,  then  proceeded  w-ith  the  extraction.  The  tooth 
was  a  lower  bicuspid  and  showed  no  unusual  difficulty 
in  removal. 

"No  sooner  had  it  been  lifted  from  its  socket  than 
the  woman's  body  was  noticed  to  relax,  her  head  fell 
forward  upon  her  chest,  and  her  breathing  ceased.  Ex- 
amination disclosed  a  pulseless  wrist. 

"In  the  next  room  was  a  physician  who  was  imme- 
diately  summoned.     *     *     *     *     *     *     *  , 

"They  did  everything  that  a  competent  physician 
and  skilled  dentist  could  do  without  accomplishing 
anything. 

"You  ask  the  cause?  It  was  shock.  The  dread  and 
fright  of  the  extraction  started  an  impulse  that  prob- 
ably contracted  the  circulator}^  vessels  of  the  vaso- 
motor centers  in  the  medulla  which  in  turn  so  greatly 
interfered  with  the  action  of  the  pneumogastric  nerve 
that  the  beart  and  lungs  ceased  to  act.     *     *     '•'     *" 

A  man  went  to  a  hospital  in  England  to  A'isit  his 
father  wdio  was  mortally  ill.  After  leaving  the  hospital, 
he  dropped  dead  a  hundred  yards  from  the  gate  from 
mental  emotion.  There  was  a  post-mortem  of  both 
next  day,  the  father  dying  from  disease  in  the  hospital, 
the  son  from  shock  at  the  hospital  gate.     (Brunton.) 

A  patient  was  being  annesthetized  for  an  al;doi;iinal 


54  General  Ancesthetics  in  Dentistry. 

operation.  The  surgeon,  standing  with  his  knife  in 
hand,  awaiting  the  signal  to  operate,  with  the  point 
of  the  handle  traced  the  place  and  length  of  incision 
he  would  make — the  patient  died  immediately.  Suffi- 
ciently anaesthetized  to  be  rendered  helpless,  yet  con- 
vinced that  the  surgeon  was  beginning  the  operation, 
shock  resulted,  and  the  patient  died.  This  was  recorded, 
of  course,  as  a  death  from  anjesthesia.  Dr.  Schofield, 
in  his  recent  work  on  "The  Subconscious  A^ind,"  re- 
lates a  case  which  occurred  in  England.  A  man  was 
condemned  to  the  death  penalty;  his  head  was  on  the 
block  awaiting  the  fall  of  the  ax,  when  he  was  re- 
prieved; but  he  was  found  to  be  already  dead  from 
shock. 

The  French  surgeons  report  this  case :  A  patient 
was  to  be  operated  upon,  and  his  condition  contra-indi- 
cated the  administration  of  general  anaesthetics ;  but 
he  demanded  chloroform,  and,  to  calm  him,  the  surgeon 
held  a  cloth  without  chloroform  before  his  face.  The 
patient  had  taken  but  four  inhalations  of  air,  when 
he  died. 

A  gentleman  was  sitting  in  the  chair  of  a  Parisian 
dentist,  mouth-prop  inserted,  ready  to  have  admin- 
istered nitrous  oxid.  The  operator,  the  inhaler  in 
hand,  turned  aside  to  signal  the  assistant  to  turn  on 
the  gas;  resuming  his  position  at  the  chair  to  make  the 
administration,  found  the  patient  dead.  Had  this 
patient  taken  even  one  inhalation  of  the  gas,  it  would 
have  been  recorded  as  a  nitrous  oxid  gas  death. 

Just  recently  at  Ackley,  Iowa,  a  horse  was  tied  to 
a  post  near  a  railroad  track.     The  engine  came  thun- 


General  Ancesthetics  in  Dentistry.  55 

dering  along  at  a  rapid  speed,  and,  when  opposite  the 
horse,  the  whistle  gave  a  tremendous  shriek.  The 
horse  reared,  plunged  forward  and  fell  dead  from 
fright — shock. 

In  the  second,  the  physical,  we  classify  those  cases 
of  shock  which  are  dependent  upon  too  sudden,  too 
frequent,  too  painful,  too  forcible,  or  too  prolonged 
stimulation  of  the  afferent  nerves.  While  the  psychical 
equation  is  also  present  in  this  second  group,  and  in 
many  cases  cannot  be  eliminated,  yet  it  is  the  more 
tangible  causes  of  shock,  those  which  may  be  denom- 
inated exciting  causes,  that  will  be  taken  into  consid- 
eration. The  etiological  factor  in  this  group  is  some 
physical  irritant. 

In  reporting  mortalities  resulting  from  chloroform 
anaesthesia,  it  is  frequently  said  that  the  patient  died 
after  the  first  two  or  three  inhalations.  Some  of  these 
deaths  are  the  result  of  mental  inpressions,  fear;  others 
from  direct  irritation  of  the  sensory  nerves  of  the  nares, 
pharynx,  bronchi  or  lungs.  Some  writers  are  of  the 
opinion  that  nearly  all  of  the  chloroform  mortalities 
that  occur  from  just  a  few  inhalations  of  the  ancesthetic 
are  purely  psychic.  If  this  were  true,  deaths  would 
more  frequently  occur  at  the  very  beginning  of  the  ad- 
ministration of  other  anaesthetics.  We  know  that  a 
handkerchief  on  which  has  been  placed  chloroform, 
and  even  aqua  ammonia,  held  under  the  nose  of  a  rab- 
bit, will  cause  its  heart  to  cease  beating.  The  wonder 
is  there  are  not  many  more  chloroform  mortalities 
when  we  take  into  consideration  the  careless  manner 
in   which  chloroform   is   administered.     It  onlv   takes 


56  General  Ancesthetics  in  Dentistry. 

two  per  cent,  of  chloroform  vapor  to  anesthetize  a 
patient  and  one  per  cent,  is  sufificient  to  maintain  anaes- 
thesia, but  this  is  either  not  well  understood  or  is  not 
believed,  because  during  an  average  anaesthesia,  many, 
many  times  this  amount  of  chloroform  is  usually  em- 
ployed. All  those  deaths,  that  occur  during  the  first 
minute  or  two  of  chloroform  anaesthesia  are  the  result 
of  shock,  either  from  the  first  cause  assigned,  fear,  or 
the  second,  by  too  suddenly  irritating  the  afferent 
nerves. 

If  chloroform  is  administered  in  a  very  dilute  form, 
and  gently,  we  get  no  shock  in  either  plants  or  animals, 
as  Sir  James  Y.  Simpson  has  demonstrated.  He  made 
some  very  interesting  experiments  on  that  most  deli- 
cate of  all  plants,  the  sensitive  plant,  the  mimosa 
pudica.  If  you  touch  the  leaves  of  the  sensitive  plant, 
they  at  once  fold  up  and  fall  down  upon  the  stock.  Sir 
James  who  discovered  the  ansesthetic  properties  of 
chloroform  found  that  if  you  subjected  this  plant  to  the 
strong  vapor  of  chloroform,  the  leaves  would  close  up 
just  as  if  you  had  irritated  them  in  any  other  way.  But 
if  you  apply  a  very  dilute  chloroform  vajor,  you  can 
now  handle  the  sensitive  plant  and  it  does  not  irritate 
or  cause  it  to  fold  up.  In  other  words,  it  has  been 
anaesthetized  by  the  mild  vapor  without  irritation, 
while  the  strong  vapor  produced  shock  and  defeated 
angesthetization.  The  mild  vapor  does  not  produce  any 
irritation  whatever,  simply  produces  anjesthesia.  The 
same  is  true  of  the  rabbit  and  the  guinea-pig-— diluted 
chloroform  vapor  produces  anaesthesia  without  irri- 
tation, l)ut,  if  a  strong  vapor  is  used  suddenly,  it  will 


General  Anaesthetics  in  Dentistry.  57 

irritate  the  vagus  reflexly  through  the  fifth  nerve  and 
the  respiration  will  cease ;  what  is  true  of  plants  and 
animals  holds  good  in  that  higher  animal,  man. 

The  irritating  general  anaesthetics,  then,  should  be 
administered  in  dilute  form,  starting  with  just  a  trace 
of  vapor,  and  gradually  increasing  the  strength  as  the 
nerves  along  the  respiratory  channel  become  accus- 
tomed to  the  anaesthetic,  or  are  themselves  locally 
anaesthetized. 

There  is  a  form  of  shock  that  results  from  blows 
or  external  pressure.  A  blow  suddenly  delivered  upon 
the  abdomen  or  about  the  heart  sometimes  produces 
death  from  nervous  shock  affecting  the  solar  plexus. 
If  I  remember  correctly,  it  was  a  blow  received  in 
the  stomach  of  Corbett,  delivered  bv  Bob  Fitzsimmons, 
that  "knocked  him  out" ;  a  little  harder  blow  would 
haA^e  completely  paralyzed  the  solar  plexus  and  ended 
the  life  of  Mr.  Corbett. 

Before  the  introduction  of  general  anesthetics,  the 
methods  used  to  induce  anaesthesia  were  peculiar  and 
almost  ludicrous.  One  method  was  for  three  strong 
men  to  stand  on  each  side  of  the  patient  who  was 
placed  in  the  recumbent  position,  and  at  a  given  signal 
the  patient  was  raised  quickly  to  the  standing  position. 
The  head  was  raised  quicker  than  the  blood  could  fol- 
low it,  and  this  temporary  anaemia  of  the  brain  brought 
about  a  faint,  during  the  continuance  of  which  the 
operation  was  performed.  It  was  proposed  by  the  late 
physiologist.  Dr.  Waller,  to  produce  anaesthesia  not  by 
simply  raising  the  man,  but  by  garrotting  him,  simply 
putting   the   finger   and   thumb   upon   the   carrotid   ar- 


58  General  AncEsthetics  in  Dentistry. 

teries,  compressing  them  suddenly,  and  thus  rendering 
the  patient  insensible;  but  the  introduction  of  anaes- 
thetics prevented  either  of  these  plans  from  having  a 
very  wide  use.  (Brunton.)  This  sudden  compression 
of  the  carotids  to  produce  insensibility  is  one  of  the 
jiu  jitsu  tricks  of  the  Japanese.  A  person  is  rendered 
immediately  insensible  by  shock,  and,  if  the  force  be 
applied  too  vigorously,  the  patient  does  not  revive. 

Most  persons  killed  by  hanging  or  strangling  die 
from  shock,  not  suffocation.  A  sudden  pressure  on  the 
larynx  and  trachea  causes  reflexly,  through  the  nervous 
system,  a  sudden  stoppage  of  the  heart  and  lungs.  It 
is  not  that  the  respiration  ceases  and  the  heart  con- 
tinues its  action,  as  in  suffocation,  but  the  heart  and 
lungs  both  cease  to  perform  their  functions.  It  is  said 
that  more  than  half  of  the  people  who  die  from  falling 
into  water  are  not  drowned ;  they  do  not  die  from 
suffocation,  but  from  shock.  (Brunton.)  They  are 
either  frightened  to  death,  or  the  sudden  shock  of 
falling  into  cold  water  acts  reflexly,  and  both  respira- 
tion and  circulation  are  discontinued. 

External  pressure  plays  such  an  important  part  in 
the  production  of  shock  that  every  possible  precaution 
should  be  taken  in  administering  anaesthetics  to  pre- 
vent the  slightest  pressure  on  the  throat,  lungs,  chest 
or  abdomen.  The  position  of  the  patient  has  much  to 
do  with  the  pressure  on  the  parts  mentioned.  A  pa- 
tient, who,  in  the  standing  position,  thinks  her  corset 
quite  loose,  upon  taking  her  seat  in  the  dental  chair, 
through  readjustment  of  the  abdominal  organs,  finds 
the  corset  very  tight,   and  the   fatter  the  patient  the 


General  Anaesthetics  in  Dentistry.  59 

more  she  spreads  out  in  the  sitting  posture.  There  is 
only  one  safe  method  of  procedure ;  that  is,  refuse  ab- 
solutely to  anaesthetize  any  woman  unless  the  corset 
is  removed  no  matter  what  anaesthetic  is  employed. 

The  same  is  true,  in  a  lesser  degree,  of  all  bands 
and  collars,  loose  enough,  perhaps,  in  the  upright  posi- 
tion, but  the  patient  under  anresthesia  may  slide  into 
a  position  that  will  render  the  collar  and  band  ex- 
tremely tight  without  the  anaesthetist  observing  it. 
Even  should  no  dangerous  symptoms  arise  from  oper- 
ating without  removing  the  corset  and  collar,  1  am 
satisfied  that  most  of  the  nausea  occurring  in  dental 
chairs  during  or  as  the  result  of  administering  nitrous 
oxid  and  somnoform  is  the  result  of  tight  clothing. 
No  woman  is  as  easily  and  as  successfully  anaesthetized 
in  tight  clothing  as  in  loose  clothing,  and  most  of  the 
failures  to  successfull)^  and  comfortably  anaesthetize 
patients  is  the  result  of  carelessness  or  ignorance,  on 
the  part  of  the  dental  surgeon,  in  regard  to  properly 
arranging  the  patient  for  the  operation.  If  it  should 
become  necessary  to  resort  to  resuscitory  measures, 
the  corset  is  always  in  the  way,  and  the  patient  might 
die  before  you  could  free  the  muscles  of  respiration 
or  massage  the  muscles  about  the  heart. 

Spasm  of  the  glottis  is  the  condition  to  which  I 
will  next  call  your  attention.  Bear  in  mind  that  spasm 
of  the  glottis  may  arise  at  the  very  beginning  of  the 
administration  of  an  anaesthetic,  through  carelessness, 
if  the  vapor  be  too  strong ;  and  at  the  conclusion  of  the 
anaesthetic,  from  the  accumulation  of  blood,  mucus, 
vomit,    etc.,    in   the    larynx.      Spasm    of   the    glottis    is 


60  General  Ancesthetics  in  Dentistry. 

the  condition  that  gives  me  the  most  anxiety  in 
my  anccsthetic  work.  It  is  the  condition  that  I 
ever  bear  in  mind  in  administering"  anaesthetics, 
the  condition  for  which  I  watch  most  closely  and 
constantly.  As  I  have  previously  said,  this  con- 
dition may  arise  at  the  beginning  of  anaesthesia,  and 
in  operations  in  the  mouth,  nose  and  pharynx,  at  the 
close  of  or  during  the  operation.  When  it  occurs  at 
the  beginning  of  anaesthesia,  it  usually  arises  from  too 
suddenly  or  too  powerfully  stimulating  the  sensory 
nerves  along  the  respiratory  tract.  The  cases  we  have 
just  been  considering,  those  in  which  patients  died 
after  taking  but  two  or  three  inhalations  of  the  anges- 
thetic,  <weve  deaths  from  spasm  of  the  glottis.  The 
remedy  has  already  been  suggested :  begin  the  anaes- 
thesia with  a  very  dilute  anaesthetic-laden  vapor,  the 
patient  taking  normal  inhalations  in  the  beginning. 
If  you  will  bear  in  mind  constantly  what  I  have  said 
about  always  beginning  with  a  dilute,  non-irritating 
vapor,  you  will  probably  never  see  a  case  of  spasm  of 
the  glottis  in  the  first  stages  of  anaesthesia.  Spasm  of 
the  glottis  occurring  after  beginning  to  operate,  or  at 
the  close  of  the  operation,  is  a  very  different  matter. 
I  watch  for  this  condition  more  earnestly,  if  possible, 
than  that  form  of  spasm  of  the  glottis  which  results 
from  faulty  anaesthesia. 

We  will  next  discuss  spasm  of  the  glottis  occurring 
during  or  at  the  close  of  the  operation,  the  exciting 
cause  being  irritation  of  the  nares,  pharynx,  larynz.  or 
trachea,  the  :^'^sult  of  blood,  mucus,  saliva,  vomit,  or 
other  foreign  matter  collecting  in  the  throat.     I  stated 


General  Ancc^ihctics  in  Dentistry.  6l 

in  a  previous  lecture  that  th6  one  condition  I  watched 
for  most  carefully,  and  the  one  that  caused  me  the 
most  anxiety  in  my  anaesthetic  work  was  the  passage 
into  and  a  collection  of  blood  in  the  throat,  lest  frorh 
pressure  or  interruption  of  respiration  the  vagus  be  in- 
terrupted sympathetically  and  shock  result.  One  of  the 
brightest  young  dental  surgeons  Iowa  ever  produced 
met  his  death  from  shock,  the  result  of  blood  collecting 
in  the  throat  following  a  tonsilotomy. 

As  long  as  the  patient  swallows  freely,  there  is 
nothing  to  dread ;  but  at  that  stage,  when,  with  some 
patients,  there  is  contraction  of  all  the  muscles  of  the 
body  and  a  stiffening  and  hardening  of  the  throat  mus- 
cles, a  serious  condition  may  arise.  In  this  condition, 
the  patient  can  neither  spit  nor  swallow,  and  it  is 
important  that  blood  be  prevented  from  entering  the 
throat.  Methods  of  preventing  blood  accumulating  in 
the  throat  are  fully  described  in  the  lecture  on  "Ele- 
ments of  Success." 

Eliminating  spasm  of  the  glottis,  blood  should  be 
prevented  from  entering  the  stomach,  because  it  nearly 
always  causes  nausea.  If  patients  are  not  nauseated  in 
the  office,  they  are  apt  to  be  nauseated  after  going 
home,  and  the  anaesthetic  is  usually  blamed  or  con- 
demned. Care  must  be  taken  to  prevent  teeth  or  roots 
of  teeth  from  entering  the  throat,  especially  the  larynx. 
Teeth  have  been  known  to  pass  into  the  pharynx,  enter 
the  trachea  and  produce  spasm  of  the  glottis,  m.iking 
tracheotomy  necessarv. 

E^•en  with  nitrous  oxid  and  somnoforni.  when  pos- 


62  General  AncBsthetics  in  Den.istry. 

sible,  have  your  patients  eat  only  moderately,  or  not  at 
all,  prior  to  anaesthesia.  Three  hours  after  eating  a 
meal  is  a  convenient  time  to  administer  these  anges- 
thetics.  Although  I  anresthetize  patients  any  hour 
that  they  happen  to  come  with  nitrous  oxid  or  somno- 
form,  if  I  have  the  privilege  of  making  an  appointment, 
I  select  the  hours  of  eleven  o'clock  in  the  morning  and 
between  three  and  four  o'clock  in  the  afternoon.  Al- 
though nausea  rarely  occurs  with  these  anaesthetics  and 
is  not  apt  to  happen,  yet  we  should  take  every  precau- 
tion to  prevent  it.  Should  nausea  occur  while  the  pati- 
ent is  anaesthetized,  there  is  risk  of  undigested  food, 
from  its  presence  and  position,  causing  spasm  of  the 
glottis.  This  matter  was  forcibly  brought  to  my  atten- 
tion on  an  occasion  when  I  Avas  administering  nitrous 
oxid  at  my  clinic,  before  a  large  class  of  students  at  the 
College  of  Dentistry,  State  University  of  Iowa.  The  in- 
haler which  I  was  accustomed  to  use  at  this  clinic  re- 
fused to  work;  as  a  substitute,  an  old  hard  rubber 
tube  which  passed  into  the  mouth  was  resurrected, 
the  rubber  hood  falling  around  the  nose  and  face. 
With  this  hard  rubber  tube  in  the  mouth,  about  an 
inch  in  diameter,  it  did  not  occur  to  me  that  a  mouth- 
prop  was  necessary.  I  proceeded  to  administer  nitrous 
oxid,  and  when  satisfied  that  the  patient  was  suffi- 
ciently anaesthetized  for  the  operation,  removed  the 
inhaler  and  his  mouth  closed  with  the  speed  and  force 
of  an  old-time  musk-rat  trap.  Immediately  he  became 
nauseated,  and  the  contents  of  his  stomach,  undigested 
food,  filled  his  nose,  mouth,  and  pharynx.    His  face  be- 


General  Anaesthetics  in  Dentistry.  63 

came  purple,  then  black;  he  ceased  to  breath.  It  was 
impossible  at  first  to  force  his  jaws  apart.  AVe 
bounced  him  up  and  down  in  the  chair  hoping-  to  force 
back  the  undigested  food.  Fortunately,  two  front 
teeth  were  missing.  I  inserted  my  finger,  assistants 
keeping  up  the  bouncing,  and  some  air  must  have  en- 
tered his  lungs,  for  at  this  stage  of  the  resuscitation, 
he  opened  his  mouth  and  discharged  the  contents  of 
his  stomach.  It  was  the  first  and  only  alarming  con- 
dition I  have  ever  witnessed  in  my  anaesthetic  work. 
This  experience  was  worth  more  to  me  and  to  the  class 
than  a  hundred  cases  in  which  the  result  was  perfect. 
I  was  at  fault,  first,  in  that  I  did  not  use  a  stable 
mouth-prop ;  second,  in  that  I  did  not  inquire  how  long" 
it  had  been  since  the  patient  had  eaten  his  last  meal. 
The  hour  of  dinner  is  so  universally  noon  in  this  State, 
and,  as  the  clinic  was  arranged  purposely  between  the 
hours  of  three  and  four,  I  did  not  make  the  usual  in- 
quiry. The  patient  informed  me  afterwards  that  he 
had  onl_v  finished  his  dinner  a  few  minutes  before  com- 
ing to  the  clinic.  We  came  very  nearly  having  a  fatal- 
ity, and  the  fault  was  all  my  own.  Had  this  young 
man  died,  his  death  would  have  been  recorded  as  a 
nitrous  oxid  death.  Had  the  mouth-prop  been  in  posi- 
tion, he  would  simply  have  lost  his  dinner,  and  the  case 
forgotten  long  ago. 

When  ether  and  chloroform  are  the  anaesthetics  em- 
ployed, every  preliminary  precaution  known  should 
be  taken  to  prevent  nausea.  This  matter  of  preventing 
nausea  as  the  result  of  ether  and   chloroform   anaes- 


64  General  AncBsthetics  in  Dentistry. 

thesia  and  its  treatment  will  be  considered  in  another 
lecture. 

Another  cause  of  shock  is  operating  in  the  prelimin- 
ary stages  when  anaesthesia  is  being  induced,  or  in  the 
later  stage  when  it  is  passing  off.  If  you  will  investi- 
gate the  matter  ascertaining  at  what  time  during  anass- 
thesia  deaths  occur,  you  will  discover  nearly  all  the 
fatalities  happen  during  partial  anesthesia,  that  very 
seldom  is  a  mortality  reported  during  profound  anaes- 
thesia. 

Lauder  Brunton  speaks  of  having  witnessed  only 
one  death  under  anaesthetics.  It  was  a  man  who  w^as 
having  the  supra-maxillary  bone  removed  for  malig- 
nant disease,  and  the  whole  of  the  orbit  was  exposed. 
On  account  of  the  risk  of  blood  running  down  into  the 
trachea  and  choking  him  during  anesthesia,  he  only 
had  a  few  drops  of  choloroform  at  the  beginning  of 
the  operation,  just  enough  to  allow  the  preliminary 
incision  to  be  made.  The  rest  of  the  operation  was 
conducted  without  any  anaesthetic,  and  the  man  died 
on  the  table  from  the  shock  of  the  operation. 

It  is  important,  even  in  the  matter  of  extracting 
t'eeth,  that  the  patient  be  sufficiently  anesthetized  be- 
fore beginning  to  operate.  Do  not  begin  to  operate 
until  you  are  satisfied  that  pain  will  not  be  felt,  and 
be  sure  to  stop  extracting  before  the  patient  is  suffi- 
ciently awake  to  feel  pain.  In  my  early  professional 
experience,  I  had  great  difficulty  in  making  physicians 
understand  this  when  administering  anesthetics  for 
me  for  the  extraction  of  teeth.    As  soon  as  the  patient 


General  Ancesthetics  in  Dentistry^  65 

was  rendered  helpless,  they  would  insist  on  me  begin- 
ning to  operate,  and  near  the  conclusion  of  the  opera- 
tion, they  would  say,  the  patient  struggling  and 
screaming",  "Go  ahead,  I  will  hold  her  hands  and  she 
won't  remember  it  when  she  comes  out."  This  is 
always  a  dangerous  procedure,  and  should  not  be 
sanctioned  by  the  dentist  or  allowed  in  the  dental 
office.  In  the  year  1906,  thirty  chloroform  deaths 
occurred  in  dental  chairs.  The  percentage  of  deaths 
from  chloroform  in  dental  chairs  is  larger  than  the 
percentage  of  deaths  from  chloroform  in  the  office  of 
the  physician,  the  home  of  patients,  or  in  hospitals. 
It  is  well  to  bear  in  mind  that  some  patients  are  more 
susceptible  to  the  influence  of  anaesthetics  than  others. 
Patients  have  idiosyncrasies  in  regard  to  anaesthetics, 
the  same  as  with  other  drugs.  On  one  occasion,  a  pa- 
tient returned  to  my  office  with  a  pericemental  in- 
flammation, the  result  of  an  immediate  root  filling. 
My  iodine  and  creosote  bottle  accidentally  fell  from 
my  hand,  struck  the  iron  base  of  the  chair  and  broke. 
In  this  predicament  I  saturated  a  small  pellet  of  cotton 
with  chloroform  and  applied  it  to  the  gum  as  I  v.'ould 
have  applied  the  iodine  and  creosote  solution.  That 
amount  of  chloroform  was  in  this  case  sufficient  to 
produce  sleep  of  five  minutes  duration.  Having  dis- 
covered that  this  patient  was  so  susceptible  to  chloro- 
form, on  several  subsequent  occasions,  with  the 
amount  of  chloroform  indicated,  I  prepared  a  number 
of  sensitive  cavities  for  fillings.  Had  it  been  necessary 
for  this  young  woman  to  take  chloroform  for  a  surgi- 


66  General  AncBsthetics  in  Dentistry. 

cal  operation,  being  so  susceptible  to  its  influence,  the 
quantity  usually  administered  in  the  beginning  by 
most  anaesthetists  might  have  produced  shock. 

It  is  important,  then,  in  the  very  beginning  of  anaes- 
thesia, with  all  irritating  anaesthetic  agents  that  the 
narcotic-laden  vapor  should  be  administered  in  a 
verv  dilute  form. 


General  Ancesthetics  in  Dentistry.  67 


LECTURE  VI. 
Dental  Fatigue. 

We  have  said  that  shock  is  exhaustion  of  the  medul- 
lary centers,  the  result  of  irritating  the  sensory  (affer- 
ent) nerves;  this  condition,  in  a  milder  degree,  con- 
stitutes fatigue.  Shock  is  dependent  upon  too  sudden, 
too  frequent,  too  painful,  too  forcible,  or  too  prolonged 
stimulation  of  the  afferent  nerves ;  the  same  is  true  of 
fatigue.  Dental  fatigue  and  dental  shock,  then,  differ 
only  in  degree.  Surgical  shock  is  a  dangerous  condi- 
tion and  the  general  surgeon  uses  every  precaution  to 
prevent  it.  Dental  fatigue  bordering  on  shock  must 
be  handled  with  the  greatest  of  care  by  the  dental 
surgeon  to  avert  shock. 

Every  dental  surgeon  has  and  every  dental  surgeon 
will  continue  to  have  his  quota  of  those  nervous,  high- 
strung  patients,  many  of  whom  suffer  with  pain  days, 
weeks,  and  even  months  before  they  can  nerve  them- 
selves to  the  ordeal  of  visiting  the  dentist.  Many  of 
them  will  tell  you  afterwards  that  they  got  as  far  as 
the  door  two  or  three  times  and  returned  home  again. 
I  recall  a  case  just  now  of  a  young  woman  who  told 
me  she  had  walked  to  mv  office  on  three  successive 
days  a  distance  of  seven  miles,  through  the  snow,  with 
the  thermometer  twenty  degrees  below  zero,  for  the 


68  General  Ancesthetics  in  Dentistry. 

purpose  of  having  a  tooth  extracted.  Each  time  the 
tooth  stopped  aching  when  she  started  up  the  steps, 
and  not  till  the  third  trip,  could  she  muster  up  suffi- 
cient courage  to  enter  the  office.  Such  patients  are 
to  be  pitied,  because  their  mental  suffering  far  exceeds 
the  severest  pain  that  could  possibly  be  inflicted.  Re- 
cently a  patient  said  to  me,  as  she  sat  in  my  chair  ready 
to  be  anzesthetized,  pale  and  trembling  with  fear  (not 
afraid  of  the  anaesthetic,  but  afraid  she  would  be  hurt 
in  spite  of  the  aneesthetic)  :  "Doctor,  give  me  enough. 
please,  so  I  will  not  feel  the  pain ;  I  had  rather  never 
wake  up  than  to  have  you  hurt  me."  An  anaesthetic 
for  this  patient  was  her  only  salvation.  It  would  have 
been  dangerous  to  have  extracted  for  this  patient  with- 
out an  an£esthetic.  The  mind  has  a  powerful  influ- 
ence over  the  body — positively,  constructively,  by  en- 
abling it  to  overcome  obstacles ;  and  negatively,  de- 
structively, by  acting  adversely  on  the  body. 

Such  patients  must  be  handled  with  the  greatest  of, 
care.  At  the  first  sitting,  with  this  class  of  patients, 
if  only  an  examination  is  to  be  made  or  soft  decay  re- 
moved to  make  a  treatment  for  pulpitis,  the  face  be- 
comes pale,  respiration  impaired,  circulation  oft",  the 
skin  moist,  and,  if  too  sudden,  too  painful,  or  too  pro- 
longed irritation  be  made,  the  centers  governing  res- 
piration and  circulation  are  exhausted,  fatigue  super- 
venes, and  shock  follows.  In  other  words,  too  great 
a  demand  on  nerve  centers  exhausts  them,  and  they  re- 
fuse to  act.  This  state  is  present,  under  other  forms 
of  stimuli,  such  as  occur  in  the  painful  preparation  of 
■cavities,    removing    pulps    of    teeth,    polishing    fillings,. 


General  Ancestheiics  in  Dentistry.  69 

and  the  many  forms  of  nerve-racking  processes  which 
make  up  the  daily  operations  of  the  dental  surgeon. 
Often  the  class  of  patients  who  seem  to  be  bearing  the 
irritation  of  dental  operations  well  will  tell  you  to  go 
ahead  and  finish  what  you  are  doing,  but  all  at  once 
they  turn  pale,  perspiration  breaks  out  on  their,  faces, 
and  they,  in  spite  of  their  marvelous  force  of  will,  are 
exhausted.  This  is  what  I  mean  by  dental  fatigue.  In 
this  condition,  we  have  exhausted  the  reserves  of  the 
patient;  we  have  brought  about  a  panic,  more  or  less 
serious. 

The  general  surgeon  employs  anaesthetics  to  pre- 
vent shock;  the  dental  surgeon  should  employ  anaes- 
thetics to  prevent  fatigue  and  avert  shock.  A  small 
amount  of  nitrous  oxid,  ethyl  chloride,  somnofprm,  or 
chloroform  will  soothe  the  fibrille  of  the  nerves  so  that 
they -will  not  send  $o  frequent  or  so  strenuous  calls 
to  the  brain.  We  have  an  illustration  of  this  in  patients 
who  have  embraced  Christian  Science.  They  have 
practiced  thst  form  of  nerve  inhibition  which  their  be- 
lief calls  for,  till  the  end  organs  no  longer  telegraph 
the  pain  sensations  to  the  upper  levels  of  the  biain, 
in  which  is  located  the  seat  of  consciousness.  Anaes- 
thetics accomplish  the  same  result  by  numbing  those 
in-carrying  nerves  of  sensation  so  that  they  do  not 
vibrate  to  peripheral  stimuli.  The  Christian  Scientist 
has  learned  to  do  the  same  thing  that  the  auto-hypno- 
tist has  learned  to  do;  overcome  or  prevent  pain  by 
nerve  inhibition.  I  resided  for  a  while  in  a  little  town 
in  eastern  Iowa.  Among  my  patients  was  a  Mrs.  P- — . 
Mrs.  P — 's.  teeth  were  of  poor  structure,  and   I   think 


70  General  AncBsthetics  in  Dentistry. 

the  most  sensitive  I  have  ever  been  called  upon  to 
treat.  All  I  could  accomplish  or  hope  to  accomplish 
on  Mrs.  P —  was  to  secure  dryness  of  cavity  suffi- 
cient to  retain  cement  for  a  while.  No  attempt  at  cav- 
ity preparation  was  ever  made.  We  both  congratu- 
lated ourselves  if  we  could  succeed  in  protecting  the 
teeth  from  the  irritants  of  the  mouth.  Such  dentistry 
afforded  only  temporary  relief,  and  Mrs.  P —  was  my 
most  constant  and  persistent  patient.  I  moved  from 
the  town  of  A —  to  one  of  our  larger  cities,  C — .  One 
day  three  years  later,  a  patient  opened  the  office  door 
and  walked  in;  it  was  Mrs.  P — .  That  feeling  of 
fatigue  we  are  now  discussing  came  over  me— that 
dizzy,  fainting,  all-gone  feeling.  I  had  hoped  that  I 
would  never  have  to  "work  for  Mrs.  P —  again,  and  I 
argued  with  myself  what  course  to  pursue  as  I  con- 
tinued with  my  patient  before  greeting  her.  I  ap- 
proached her  and  said:  "Good  morning,  what  can  I 
do  for  you?"  She  replied:  "You  do  not  remember  me, 
do  you  ?"  I  said :  "Yes,  I  do ;  you  are  Mrs.  P—  of  A—." 
"My  teeth  have  all  gone  to  pieces  since  you  left  A — , 
and  I  want  an  appointment,  for  we  are  living  here 
now,  and  I  can  come  at  any  time  and  as  often  as  you 
wish  me."  I  sat  down  by  her  side  and  said:  "Mrs. 
P — ,  you  know  that  your  teeth  are  so  sensitive  that  I 
can  not  operate  for  you  properly."  There  are  a  num- 
ber of  excellent  dentists  here,  and  I  prefer  that  you 
have  your  work  done  by  some  other  operator.  She 
made  reply:  "I  will  not  do  anything  of  the  kind.  I 
am  a  Christian  Scientist  now,  and  it  will  not  hurt  me 
one  bit  to  have  my  teeth  filled."     I  told  her  if  that 


General  Ancesthetics  in  Dentistry.  71 

was  the  case  of  course  it  would  not  hurt  her,  and  gave 
her  an  appointment.  Christian  Science  was  new  then, 
and  this  was  my  first  opportunity  to  operate  for  a 
Christian  Scientist. 

I  was  expecting  the  same  condition  of  affairs  in  a 
modified  degree.  I  looked  for  some  improvement  in 
the  matter  of  self-control,  but  it  never  occurred  to  me 
that  she  would  prove  other  than  a  most  exasperating 
patient.  The  morning  of  the  appointment  arrived ;  so 
did  Mrs.  P — .  All  of  her  anterior  teeth  were  carious 
gingivally,  the  cavities  extending  some  distance  under 
the  gum  margin.  There  were  approximal  and  occlusal 
cavities  also  in  the  anterior  and  posterior  teeth,  but  it 
occurred  to  me  that  these  cavities  along  the  gum  mar- 
gins would  afford  a  good  test,  and,  if  I  succeeded  fairly 
well  here,  there  would  be  no  doubt  about  making  sat- 
isfactory fillings  in  all  of  her  teeth. 

I  started  to  make  a  cocaine  application  to  numb 
the  gum  in  order  to  more  comfortably  adjust  the  rub- 
ber dam.  She  promptly  informed  me  that  she  did 
not  wish  any  drugs  used ;  it  was  not  necessary  in  her 
case.  I  adjusted  the  dam,  forced  the  gum  back  out  of 
the  way,  the  assistant  holding  it  by  means  of  a  liga- 
ture. I  not  only  prepared  one  cavity  that  morning, 
but  three,  and  filled  them  with  gold,  and  Mrs.  P — 
never  so  much  as  wrinkled  her  forehead.  I  made 
fillings  wherever  they  were  indicated,  and  she  would 
leave  the  chair  after  two  or  three  hours  sittings  with- 
out apparently  the  least  fatigue  or  exhaustion.  The 
first  superior  bicuspids  on  each  side  had  gradually 
crumbled  away  till  the  roots  were  completely  hidden. 


72  General  AncEsthetics  in  Dentistry. 

These  Mrs.  P —  wished  removed.  I  dissected  back  the 
gum  of  the  one  on  the  right  side,  located  the  edges 
of  the  root,  and  with  my  thinnest  blade  forceps,  pushed 
with  all  my  might;  the  bone  spread  and  the  root 
popped  out.  When  I  shoAved  it  to  her  she  said :  'Ts 
that  all  there  is  to  having  a  root  out."  I  pushed  up 
around  the  other  root  without  dissecting  the  gum,  and 
it  nipped  off  two  or  three  times,  but,  with  the  ex- 
ception of  her  face  getting  red  in  the  malar  region, 
there  was  nothing  to  show  that  she  was  the  least  dis- 
turbed physically  or  mentally  by  this  operation. 
"Great  God !"  I  said  to  myself,  "this  woman  is  the 
same  only  in  name  as  the  Mrs.  P —  I  used  to  work 
for  in  the  town  of  A — ." 

The  Christian  Science  movement  spread  rapidly  in 
that  community.  A  church  was  organized  and  they 
rented  a  room  across  the  hall  from  my  office  in  which 
to  hold  their  meetings,  and  they  must  have  appointed 
me  their  official  dentist,  for  they  came  to  me  in  num- 
bers for  their  dentistry.  Mrs.  P —  became  a  healer, 
and  would  bring  me  patients  and  remain  with  them 
and  treat  them  as  I  operated,  and  another  healer,  a 
Mrs.  L — ,  would  do  the  same  thing.  The  effect  was 
marvelous.  Once  in  a  while,  some  of  my  old  patients 
would  return  for  work,  having  in  the  mean  time  em- 
braced Christian  Science,  and  I  had  opportunities  to 
observe  the  effect  in  numerous  cases.  They  were  not 
all  like  Mrs.  P — .  Some  admitted  being  hurt;  some 
would  request  me  to  wait  a  moment,  now  and  then,; 
but  all  of  them  maintained  a  marvelous  control  over 


General  Ancesthetics  in  Dentistry.  73 

themselves,  many  complaining  of  no  pain,  others  deny- 
ing that  they  experienced  pain. 

Some  people,  by  constant  practice,  have  acquired 
the  habit  of  moving  their  scalp  backwards  and  for- 
wards; others  to  wriggle  their  ears  like  a  mule;  while 
others  with  equal  celerity  have  learned  to  throw  their 
cerebral  hemispheres  out  of  gear,  to  exercise  the  power 
of  inhibition  and  shut  off  pain  from  certain  parts  of 
the  body,  much  the  same  as  the  electric  lights  in  one 
room  of  a  house  can  be  extinguished  at  pleasure,  by 
turning  a  switch,  while  the  lights  burn  brilliantly  in 
all  other  rooms  of  the  house. 

"You  will  find  recorded  in  Fox's  'Book  of  Martyrs' 
some  very  curiqus  statements  regarding  the  condition 
of  people  who  were  tortured  by  the  Inquisition.  It  is 
said  that  some  of  them  not  only  felt  no  pain,  but  felt 
positive  pleasure,  so  that  they  regretted  being  removed 
from  the  rack,  which  seemed  to  them  a  bed  of  roses." 
(Brunton.) 

We  can  not  instruct  our  patients  how  to  use  auto- 
hypnotism,  or  in  all  cases  overpower  them  with  sug- 
gestion, or  teach  them  the  art  of  inhibiting  pain  by 
throwing  their  cerebral  hemispheres  out  of  gear,  but  I 
will  instruct  you  how  to  obtain  the  same  results,  arti- 
ficially, by  the  use  of  nitrous  oxid,  ethyl  chloride,  som- 
noform  and  chloroform  vapor. 

Hypnotism  is  the  ideal  ancesthetic.,  the  anaesthetic 
par  excellent;  but  the  dental  profession  is  not  ready 
for  this  yet.  What  they  are  waiting  for  I  do  not  know. 
But  the  dentists  are  waiting,  holding  back,  I  suppose, 
iust  as  thev  have  delayed   availing  themselves  of  the 


74  General  AncEsthetics  in  Dentistry. 

use  of  general  ansesthetics  for  dental  operations,  till  the 
general  public  demands  and  compels  them  to  adopt 
their  use. 

Some  seventeen  years  ago,  Dr.  Chas.  Davis  of  Chi- 
cago, surgeon  in  charge  of  the  Temperance  Hospital, 
hypnotized  a  patient  for  me,  and,  in  this  hypnotic  state 
lasting  about  forty-five  minutes,  Dr.  W.  E.  Hodgin 
and  myself  prepared  and  filled  a  cavity  with  gold  in 
the  upper  left  central  incisor.  This  patient  did  not 
know  that  he  was  to  have  a  tooth  filled.  The  tooth 
was  a  difficult  one  over  which  to  adjust  the  rubber 
dam,  and  we  had  Dr.  Davis  make  the  suggestion,  "dry 
mouth,"  and  there  was  no  moisture  present,  and  cot- 
ton rolls  were  used  to  hold  the  lip  out  of  the  way. 
Further,  he  was  commanded  to  hold  his  mouth  open, 
and  this  he  did  throughout  the  entire  operation.  Dr. 
Davis  was  in  an  adjoining  room  and  did  not  return  till 
we  had  the  filling  completed.  The  doctor  aroused 
him  at  our  request  and  when  we  showed  him  the  filling 
he  was  the  most  surprised  individual  I  have  ever  seen. 
Suggestion  is  used  to-day,  in  a  greater  or  less  degree, 
by  all  physicians,  and  hypnotic  clinics  have  been 
established  in  which  all  diseases  are  treated  under 
hypnotism. 

The  psychic  causes  of  dental  fatigue  can  not  be 
eliminated  from  the  direct  or  physical  causes.  The 
psychic  causes  are  always  present  and  augment  the 
physical.  The  following  are  the  most  common  physi- 
cal causes;  inflicting  pain  too  suddenly — for  instance, 
thrusting  a  broach  into  a  pulp  which  is  supposed  to  be 
anaesthetized  with  cocaine  but  the  cocaine  has  not  been 


General  Ancesihetics  in  Dentistry.  75 

absorbed;  holding'  the  rapidly  rotating  bur  too  long  on 
the  sensitive  dentine,  without  lifting  it  frequently  so 
that  both  the  tooth  and  bur  may  have  an  opportunity 
to  cool;  rapid  and  prolonged  grinding  with  a  corun- 
dum-stone, whether  shaping  a  tooth  for  a  crown  or 
completing  a  gold  filling  with  sandpaper  strips  and 
discs  when  the  patient's  vital  force  has  already  been 
overtaxed;  or  a  combination  of  two  or  three  of  the 
above  causes  at  the  same  sitting;  extraction  of  a  tooth 
when  the  vital  forces  have  been  lowered  from  intense 
suffering  and  loss  of  sleep ;  prolonged  effort  to  remove 
a  root  or  roots  after  the  tooth  has  been  fractured  ;  re- 
moving too  many  teeth  at  a  sitting  without  an  anaes- 
thetic. To  these  might  be  added  too  frequent  sittings 
and  sittings  of  too  lengthy  duration  even  though  the 
operation  may  not  be  painful. 

Patients  exert  themselves  to  the  limit  of  endur- 
ance in  the  dental  chair.  If  we  stop  in  time,  shock  or 
collapse  is  avoided.  AA'e  seldom  witness  an  exhibi- 
tion of  fatigue  in  the  dental  chair.  Patients  nerve 
themselves  for  the  ordeal,  store  their  energies  in  ad- 
vance, as  it  were,  as  we  charge  a  storage  battery.  It 
is  at  their  homes  after  leaving  the  office  that  the 
penalty  is  paid. 

The  remed}^  in  all  these  cases  is  to  use  enough  of 
one  of  the  available  angesthetics  to  relieve  dread  and 
fear.  The  easiest  people  to  persuade  to  take  an  anaes- 
thetic are  those  that  suffer  most.  They  are  willing 
to  take  or  do  anything  to  avoid  pain  or  knowing  about 
what  is  going  on.  For  operations  other  than  extract- 
ing, the  analgesic  stage  is  usuallv  all  that  is  necessarv. 


76  General  Ancesthetics  in  Dentistry. 

A  few  inhalations  of  chloroform,  somnoform  or  nitrous 
oxid  and  oxygen  usually  are  sufficient  to  render  oper- 
ating comfortable  for  both  the  patient  and  the  dentist. 

For  a  description  of  the  methods  employed  and  how- 
to  administer  nitrous  oxid,  nitrous  oxid  and  oxygen, 
ethyl  chloride,  somnoform,  and  chloroform  to  prevent 
dental  fatigue,  you  are  referred  to  the  lectures  on  these 
anaesthetic  agents,  individually. 

Case  I.  Miss  A — ,  a  school  teacher.  Extremely 
nervous  from  work  in  the  school-room,  presented  for 
removal  of  pulp  in  upper  right  second  bicuspid.  It 
was  simply  impossible  to  use  an  engine  on  this  tooth. 
Mouth-prop  adjusted,  nitrous  oxid  and  oxygen  was 
used,  and  pulp  removed  without  discomfort.  This 
patient  had  been  to  two  dentists  who  failed  in  their 
efforts  to  open  into  the  tooth  properly  for  nerve  devi- 
talization. This  patient  left  the  office  stimulated  and 
not  depressed,  as  on  all  former  occasions,  when  leav- 
ing the  dental  chair.  At  subsequent  sittings  a  number 
of  cavities  were  prepared  painlessly  for  fillings,  under 
nitrous  oxid  and  oxygen  analgesia. 

Case  II.  Mr.  B — ,  a  robust  man  about  forty  years 
of  age.  A  bridge  had  been  placed  in  the  mouth  sev- 
eral years  previously.  One  of  the  abutments,  an  upper 
molar,  had  not  been  devitalized.  The  pulp  had  died, 
infecting  the  tissues  above,  and  it  was  necessary  to  re- 
move the  bridge.  These  conditions  are  usually  as 
painful  as  the  dentist  is  ever  called  upon  to  treat.  The 
slightest  touch  of  the  bridge  was  simply  unendurable. 
Nitrous  oxid  and  oxygen  was  used  in  lliis  instance. 
The  crowns  were  slit,  the  bridge  remoN'cd.  and  the  inilp 


General  Anccsthetics  in  Dentistry.  77 

chamber  of  the  molar  entered  for  vent  and  drainage ; 
time  required,  about  four  minutes. 

Case  III.  A  case  of  nerve  fatigue  and  collapse. 
Mrs.  J — ,  naturally  frail,  came  to  me  for  an  extraction, 
with  the  following  history.  She  had  in  her  mouth  a 
number  of  gold  fillings  beautifully  made,  the  Black 
cavity  preparation  being  followed  precisely.  The 
operator  in  this  case  underestimated  the  vitality  of  his 
patient.  At  the  last  sitting,  she  informed  me,  she  col- 
lapsed in  the  chair,  was  unconscious  two  or  three 
hours,  and  for  months  was  confined  to  the  house  and 
could  walk  now  only  with  the  aid  of  a  cane.  \V  ith  a 
history  of  this  kind  and  the  patient  looking  more  dead 
than  alive,  an  extraction  becomes  an  important  matter. 
It  was  dangerous  to  extract  without  an  anaesthetic ;  I 
would  not  assume  that  risk.  I  administered  somno- 
form  very  gently  with  the  Stark  inhaler  admitting 
much  air  and  got  along  nicely  without  after  trouble. 

Case  IV.  Nausea,  the  result  of  nerve  irritability. 
Patient,  a  healthy  young  farmer  unused  to  dental 
operations.  Operation,  preparation  of  a  cavity  in  a 
devitalized  lower  molar  and  insertion  of  a  gold  inlay. 
The  preparation  of  the  cavity  was  about  all  he  could 
stand,  and,  when  the  inlay  was  in  position,  slight 
grinding  with  a  corundum-stone  and  sandpaper  discs 
produced  nausea,  sick  stomach  and  fainting  and  the 
operation  had  to  be  postponed.  He  remarked  that  he 
could  stand  pain,  but  the  grinding  sensation  was  too 
much  for  him. 

Case  V.  Miss  C — ,  age  fourteen.  Had  neglected 
her  teeth  on  account  of  dread  and  fear  of  the  dental 


78  General  Anceslheiics'in'Dentisiry. 

chair.  An  exposed  pulp  brought  Her  to  the  office,  blit? 
her  courage  failed.  Upon  explaining  the  use  of  nitrous 
oxid  she  readily  consented  to  have  it  used,  and  her 
teeth  in  due  time  were  all  filled,  and  her  mouth  placed 
'in  'a  healthy  condition. 

'.'  Case  VI.  Little  boy,  about  eight  years  of  age.  Was 
summoned  to  the  ofiice  of  a  dentist  to  administer 
somnoform  and  found  this  little  fellow  waiting.  The 
lower  right  central  incisor  was  in  a  state  of  acute  al- 
veolar abscess.'  I  administered  somnoform  and  his 
dentist  with  a  new  bur  in  an  electric  engine  went 
through  the  disto-approximal  surface  into  the  pulp 
chamber  and  the  pus  oozed  out.  The  administration 
of  the  anaesthetic  and  the  operation  did  not  consume 
more  than  sixty  seconds.  ■         ■   U 


General  Ancesihdics  in  Dentislry.  79 


LECTURE  VII. 
Elements  of  Success. 

Success  in  administering  ansesthetics  does  not  de- 
pend entirely  on  the  ancesthetic  employed  or  on  the 
manner  in  which  the  anesthetic  is  administered. 
There  are  a  number  of  small  details  to  which.  I  wish 
to  call  your  attention,  all  of  which  are  highly  impor- 
tant in  order  to  obtain  the  best  of  ancesthetic  results. 

The  anaesthetic  room  should  be  the  most  (juiet 
room  in  the  office.  It  should  also  be  the  most  private 
room.  The  forceps  should  at  all  times  be  kept  cut 
of. the  sight  of  the  patient..  Adjoining  the  anaesthetic 
room  should  be  a  private. .room,  the  rest  room  or  pre- 
paratory room.  In  this  room  should  be  a  dresser  with 
large  -mirror,  a  sofa  or  lounge,  wash-basin  and  water, 
and  a  large  supply  of  clean  towels..-  This  room  should 
at  all  times  be  kept  neat  and  clean,  being  especially 
careful  that  no  blood-stained  napkins  or  towels  be  in 
sight. 

^  Usher  the. patient  first  from  the  reception  room  into 
the  anaesthetic  room,  if  you  are  so  situated  that  you 
can  have  a  roorri  for  this  exclusive  purpose.  In  this 
room  get  the  history  of  the  case,  make  your  diagnosis, 
decide  on  the  operation  and  know  for  a  certain^-y  ex- 
actly what  you  intend  to  do.  sO  that  you  will  not  have 


80  General  Ancesthehcs  in  Dentistry. 

to  make  another  examination  when  the  patient  takes 
the  chair  the  second  time. 

Your  lady  assistant  now  takes  the  patient  into  the 
preparatory  room.  The  assistant  understands  that 
the  corset  must  be  removed,  no  matter  what  objections 
are  raised  by  the  patient.  The  collar  should  be  re- 
moved and  all  bands  loosened.  If  the  patient  is  dain- 
tily dressed  and  the  operation  is  one  in  which  there 
will  be  considerable  heniorrhage,  have  the  assistant 
take  off  the  waist  and  make  a  dressing-sack  of  two 
towels,  as  patients  frequently  put  their  fingers  in  their 
mouths,  and,  before  you  can  prevent  it,  will  place  their 
hands  on  their  gowns  and  soil  them,  a  situation  to  be 
avoided.  If  the  bladder  has  not  been  recently  emptied, 
the  assistant  should  attend  to  this  before  the  patient 
takes  the  chair.  Right  here  is  the  test  of  your  assist- 
ant. If  she  understands  her  business,  she  can  take  the 
most  nervous  woman  and  talk  her  out  of  her  nervous- 
ness. Instruct  your  assistant  to  keep  up  a  run  of  small 
talk.  It  will  get  the  mind  of  the  patient  from  dwelling 
on  the  operation.  You  can  take  it  for  granted  that 
the  calmest  of  patients  are  frightened,  terribly  fright- 
ened, and  the  assistant  must  get  them  over  this,  if 
possible,  before  they  get  to  you.     Have  her  tell  the 

patient  there  is  nothing  to  dread;  say,  "Mrs. took 

the  anaesthetic  yesterday  and  she  was  as  frightened 
as  you  are,  and  she  had  a  delightful  experience." 
Keep  up  the  conversation,  don't  give  the  patient  an 
opportunity  to  tell  how  scared  she  is.  She  will  get 
worse  scared  in  the  telling.  Mention  a  number  of 
pleasing  cases,  especially  some  one  of  their  acquaint- 


General  Ancesthetics  in  Dentistry.  81 

ances,  if  possible — laugh  with  them ;  there  is  nothing 
like  a  laugh  to  make  one  feel  at  ease.  If  your  assist- 
ant is  what,  in  the  language  of  the  street,  is  called  a 
"jollier,"  she  will  get  the  patient  in  a  good  frame  of 
mind  by  the  time  that  she  is  ready.  I  have  known 
patients  to  go  into  the  dressing-room  white  with  fear, 
and  step  out  into  the  operating-room  quiet  and  tran- 
quil from  the  influence  exerted  by  the  assistant. 

While  the  patient  is  being  prepared  both  physically 
and  mentally  by  the  assistant,  there  are  some  things 
to  be  attended  to  in  the  operating-room.  These  things 
I  prefer  to  do  myself.  I  select  all  instruments  that  I 
anticipa.te  using  and  boil  them  thoroughly.  I  then 
arrange  them,  on  a  table  in  the  order  in  which  I  expect 
to  use  them.  The  table  should  be  protected  b}''  a 
towel  and  another  towel  thrown  loosely  over  the  instru- 
ments, to  conceal  them  from  the  patient.  Make  ready 
the  anaesthetic  appliance,  prepare  the  hands  properly, 
and  when  everything  is  in  readiness  for  the  patient, 
and  not  until  then,  signal  the  assistant  to  place  the  pa- 
tient in  the  chair.  Not  a  moment's  time  should  now  be 
lost  in  attending  to  anything  but  the  patient.  As  soon 
as  the  door  is  opened  by  the  assistant,  begin  to  aug- 
ment what  she  has  been  saying  about  the  anaesthetic 
being  pleasant.  If  you  are  not  accustomed  to  giving 
anaesthetics,  you  will  possibly  be  worse  scared  than 
your  patient.  Don't  show  it.  Act  as  if  giving  anaes- 
thetics w^as  the  pleasantest  thing  in  life.  Try  to  make 
your  patient  feel  that  it  is  a  great  treat  to  take  an 
anaesthetic.  Reassure  the  patient  that  he  will  not  be 
hurt — then  keep  your  word.     Place  the  mouth-prop  in 


82  General  Ancesiheiics  in  Dentistry. 

position,  and  thenradjiist  the  inhaler.. ".[Rig.ht  jnow. be- 
gins your  worst. battle  withHhat  te-rribleuncvibus  .to'the 
human  mind,  fear:  /'Be  gentle,  kind  and' watchful,  .but 
above  all  things  be  masterful.;  JRemembef;  tliat;.you'r 
.enemy  to  a'successfuLa-risesthesia'isthis  laf^nt,  ^powier- 
.ful  force  which'  is  one  of  the  deepest  levels 'of  tire  "s'ub- 
conscious  mind..  Begin  to  talk  away  their  fright.:  Tell 
them,  "You  are  now  going  to  sleep  and  will  have  a  quiet 
rest  and  wake  up  when  I  callyou.  You  need  have  no 
fear,  for  this  is  sleep,  just  as  you  sleep  at  home  in 
bed.  You' are  not  afraid  when  you  go  to  sleep  a-t  h6me 
and  you  are  not  afraid  now.  I  am  watching  you  and 
caring  for  you;  nothing  can  harm  you.  Give  yourself 
up  to  this  restful  sleep.  You  are  now  getting  sleepy. 
You  are  going  to  sleep."  Keep  up  this  talk  until  you 
see  the  symptoms  of  anaesthesia.  You  will  find  it 
very  helpful  to  the  patients  as  they  are  passing  through 
those  strange  doors  of  artificial  sleep.  Suggestion  has 
a  large  place  in  my  anaesthetic  work,  and  I  heartily 
recommend  you  to  a:dopt  its  use.  With  such  sugges- 
tions as  I  have  indicated,  the  amount  of  anaesthetic 
required  will  be  reduced  to  the  minimum. 

About  a  year  ago  a  young  man  came  from  a  dis- 
tant town  to  have  extracted  the  upper  third  molars.  I 
decided  to  use  somnoform.  I  had  just  procured  a 
Stark  inhaler  and  wished  to  try  this  very  beautiful 
appliance.  The  Stark  inhaler  is  so  arranged  that  the 
■amount  of  anassthetic  required  can  be  accurately  ob- 
tained. You  can  admit  just  the  amount  of  air  needed 
ih  each  ;ciase,  or  you  can  exclude  all  an?esthetic  and  give 
.the  patient  a  few  inhalations  of  air  before  you  add  any 


General  Anceslheiic?  in  'Dentistry.  83 

anzesthetic.  I  allowed  this  patient' a  few;  inhalations 
of  air  and  gave  him. the.,  verbal,  suggestions  ab'ov.e 
indicated.  After  he  had!  taken,  about  six  inhalations 
of  air,  his  arm  dropped  to  his  side  and  he  to  all  ap.- 
pearances  was  anaesthetized,-  yet  he  had  at  that  time 
breathed  only  air.  I  placed  the  inhaler  to  my,  face 
to  see  if  I  could  be  mistaken-.  No  somnoform  was.es; 
.caping  from  the  inhaler.  He  was  in  a  state  of  anaes- 
thesia without  inhaling  any  anaesthetic.  To  be  on  the 
safe  side,  as  I  had  promised: not  to  hurt  him,  I  gave  him 
•two  inhalations  of  somnoform' with  about  half"  air. 
I  extracted  the  teeth  and  waited  for  him  to  .waken. 
He  slept  for  a  few  minutes,  and  showed  no  signs  of 
waking  up,  so  I  called  to' him  and  told  him  to/wake 
.up,  .He  did  so  and  seemed  surprised  to  find  that  the 
teeth  were  out.  I  "asked  him  if  I  had  hurt  him,  and 
he  said  that  he  did  not  feel  a  thing.  I  asked  him  what 
it  was  like.  He  said:  "It  seemed  to  me  just  like  when 
they  hypnotized  me."  The  conversation  disclosed 
the  fact  that  he  had  been  used  as  a  subject,  by  a  person 
who  was  studying  hypnotism,  and  had  thus  become 
very  susceptible  to  the  influence  of  suggestion.  I 
would  not  advise  talking  hypnotism,  or  ever  mention- 
ing the  idea  to  a  patient,  but  used  in  this  way  you  will 
find  suggestion  a  very  helpful  influence  in  anaesthetic 
work. 

Having  mentioned  the  assistant,  let  me  say  a  word 
about  her  before  we  finish  this  subject.    A  thoroughly 
trained  assistant  is  three-fourths  of  the  battle.     The 
assistant  should  be  a  cool,  level-headed  woman,  physi- 
cally strong,  non-excitable,  quick  to  think,  and  a  keen 


•84  General  Ancestheiics  in  Dentistry. 

observer.  She  should  know  anjesthetic  symptoms ; 
understand  all  resuscitation  measures,  and  how  to  ap- 
ply them ;  and  be  thorou_^hly  interested  in  the  work. 
If  you  can  not  teach  your  assistant  these  requirements; 
if  she  is  scared  and  can  not  learn  self-command,  you 
had  better  get  another  assistant,  or  get  a  trained  nurse 
to  stay  with  you  a  while  until  the  assistant  learns  how 
to  properly  assist  you.  You  can  teach  her  yourself, 
if  you  take  pains  to  do  so,  out  of  office  hours,  or  when 
you  have  leisure.  Demonstrate  the  methods  of  arti- 
ficial respiration  on  her,  and  have  her  demonstrate 
them  on  you. 

While  you  are  giving  the  anaesthetic,  the  assistant 
should  stand  on  the  left  of  the  chair  and  watch  the 
patient  closely.  When  you  begin  to  operate,  she  must 
then  watch  the  patient  for  you,  and  notify  you  at  once 
of  the  slightest  abnormality.  In  addition  to  this,  if  you 
are  to  use  more  than  one  forcep,  she  must  have  ready 
the  other  instruments  in  the  order  in  which  you  need 
them.  She  must  see  that  the  lower  lip  is  not  pinched; 
that  the  tongue  is  kept  out  of  the  way ;  that  the  cheek 
is  distended;  that  the  mouth-prop  is  removed  at  the 
right  moment  in  multiple  extractions ;  that  roots,  teeth 
and  blood  do  not  go  down  the  throat.  She  must  sponge 
the  parts;  lean  the  patient  forward  when  necessary; 
be  equal  to  any  emergency  that  may  arise,  and  do  all 
these  things  without  being  told.  All  these  things  be- 
long to  the  province  of  the  assistant — yours  is  simply 
to  take  charge  of  the  anossthesia  and  the  extraction. 

After  the  operation,  the  assistant  must  take  charge 
of  the   patient,   and   if  a  lady,   help   her   to  dress.     A 


General  AiKSsthetics  in  Dentistry.  85 

cheerful  conversation  is  just  as  helpful  now,  as  before 
the  operation.  She  must  keep  patients  encouraged 
so  that  they  will  dress  and  get  out  into  the  fresh  air. 
Some  patients  have  the  idea  that  the}^  should  lie 
around  a  while.  This  must  be  avoided;  is  not  neces- 
sary with  the  briefer  anaesthetics,  although  it  is  very 
important  after  chloroform  or  ether. 

After  the  patient  has  left,  the  assistant  can  then 
clean  all  the  instruments,  boil  them,  and  put  them 
away.  I  advise  boiling  after  use  so  that  if  an  instru- 
ment should  be  needed  in  haste,  you  can  feel  that 
it  is  not  infected  with  mouth  bacteria. 

Just  in  proportion  as  your  assistant  does  these 
things  well  for  you,  will  you  be  successful,  provided 
that  you  are  cool,  non-excitable  and  a  good  extractor. 
The  poorer  the  assistant,  the  more  of  her  work  you 
have  to  do,  the  greater  will  be  the  chance  of  failure. 
With  such  an  assistant  as  I  have  described,  you  can 
give  your  whole  attention  to  the  extracting.  The  oper- 
ator who  does  not  know  for  a  certainty  if  the  patient 
has  loosened  her  clothing;  who  relies  on  an  accom- 
panying friend  or  some  one  called  hastily  to  act  as  a 
witness,  in  lieu  of  an  assistant,  is  the  man  who  make^ 
failures  in  the  use  of  anaesthetics. 

If  you  have  not,  and  can  not  procure  such  an  assist- 
ant as  I  have  described,  then  you  must  do  your  best 
to  allay  the  fears  of  your  patients  yourself.  You  can 
do  this  before  the  patient  takes  the  chair  for  examina- 
tion, while  you  are  examining  the  case,  and  before  you 
give  the  anaesthetic. 

An  anaesthetic   should  never   be   administered  to   a 


86  General  Ancesiheiics  in  Dentisiry\ 

woman  in  a  dental  office  without  the  presence  of  an- 
other woman.  Scarcely  a  day  passes  that  some  woman 
jloes  not  sa}^  to  my  assistant,  "I  am  so  glad  to  find  a 
lady  here."  That  very  fact  has  a  quieting  and  soothing 
efifect  on  the  patient.  No  woman  wants  to  pass  into 
unconsciousness  in  the  presence  of  a  man  with  her 
clothing  unloosened,  with  only  the  protection  of  a 
towel.  Again,  especially  under  the  influence  of  nitrous 
oxid,  patients  sometimes  have  amorous  sensations, 
and  a  woman  might  dream  that  improper  liberties 
were  taken  by  the  operator.  There  is  a  case  on  record 
where  the  presence  of  mother  and  sister  failed  to  con- 
vince a  girl  that  something  improper  had  not  occurred. 
The  following  case  came  under  my  observation.  One 
Sunday  morning,  a  lady  came  to  my  office  to  have  a 
tooth  extracted,  being  accompanied  by  the  man  she 
was  to  marry  that  evening.  I  administered  nitrous 
oxid  gas,  the  man  standing  on  the  left  of  the  chair 
holding  her  hand — no  one  else  was  in  the  room.  While 
under  the  influence  of  the  anaesthetic,  the  patient  gave 
evidence  of  undergoing  an  erotic  dream.  She  awoke 
crying,  wringing  her  hands  and  screaming  at  the  top 
of  her  voice,  "Ford,  you  have  ruined  me ;  Ford,  you 
have  ruined  me,"  twenty  times  or  more.  The  situation 
was  extremely  embarrassing.  I  stepped  into  an  ad- 
joining room,  and  from  the  conversation,  every  word 
of  which  I  could  hear,  it  was  evident  that  the  bride- 
groom was  unable  to  convince  her  that  she  had  not 
been  wronged,  and  she  left  the  office  in  that  state  of 
mind.     In   "Turnbull   on   Anaesthetics,"   you   will   nnd 


General  Ancesiheiics  in  Dentistry.  87 

a  number  of  interesting" cases  that  he  has  collected' V^ry 
'.similar  to  the  one  I  have  narrated.  '  ■  ■;-:: 

"  l.r  neglected  to  say  that  while  anaesthesia  is  being 
induced  perfect  quiet  must  be  maintained  in  the  room. 
No  talking  or  whispering  should  be  tolerated,  and  no 
words  spoken,  except  those  of  suggestion  to  the  pa- 
tient. This  should  be  continued  even  though  the  pa- 
tient, apparently,  is  asleep.  Some  patients  do  not  lose 
entirely  the  sense  of  hearing.  Again,  sounds  are  ex- 
aggerated under  the  influence  of  anaesthesia  and  an 
ordinary  tone  of  voice  may  sound  very  loud  and  be 
disquieting  in  the  extreme.  For  this  reason  all  sug- 
gestions to  one  undergoing  ancesthesia  should  be  made 
in  a  quiet,  firm,  subdued  tone  of  voice.  I  speak  not 
a  word  to  anyone  in  the  room  while  inducing  anaes- 
thesia, except  to  the  patient.  All  communication  with 
the  assistant  is  conducted  by  means  of  signals.  This 
quietness  should  be  maintained  in  the  room  after  the 
operation,  while  the  patient  is  returning  to  conscious- 
ness.' Conversation  is  prohibited.  If  patients  catch  a 
few  words  while  in  the  border-land  between  sleeping 
and  waking,  they  will  imagine  that  they  knew  all  about 
the  operation.  In  a  low  tone  of  voice,  say,  "You  are 
now  through  sleeping;  you  are  waking  up,  your  teeth 
have  been  removed,  and  there  has  been  no  pain." 
Language  appropriate  will  come  naturally  to  you  for 
each  case. 

As  soon  as  the  extracting  is  completed,  napkins 
should  be  placed  in  the  mouth  to  absorb  the  blood. 
For  this  purpose,  my  assistant  uses  the  ordinary  anti- 
septic dental  napkins.     These  are  folded  so  as  to  be 


88  General  Ancesthetics  in  Dentistry. 

about  two  inches  in  length,  then  rolled  and  a  string 
tied  about  the  middle.  If  you  have  a  string  tied  to  the 
mouth-prop,  use  a  different-colored  string  for  the 
sponges.  If  only  two  or  three  teeth  are  extracted,  the 
moment  the  teeth  are  out  place  one  or  more  of  these 
napkin  rolls  under  or  over  the  sockets  of  the  extracted 
teeth,  iust  as  you  would  insert  a  mouth-prop.  If 
nitrous  oxid  gas  or  somnoform  has  been  the  anaesthetic 
used,  leave  the  patient  undisturbed  until  he  is  suffi- 
ciently awake  to  rinse  the  mouth  with  water.  First 
remove  the  napkins,  then  the  mouth-prop.  Always 
follow  this  order,  as  you  might  be  deceived  as  to  the 
amount  of  relaxation  of  the  muscles,  and  the  mouth 
might  close  tightly,  retaining  the  napkins  and  thus 
endanger  breathing. 

Never  lean  patients  forward  after  extracting  un- 
til they  are  sufficiently  aroused  to  free  their  mouths. 
There  are  two  reasons  for  this :  First,  before 
consciousness  has  returned,  the  patient  usually  passes 
through  a  dazed  and  confused  dreamy  stage,  and,  not 
knowing  where  they  are  or  what  has  occurred,  may 
have  a  bad  dream  at  being  suddenly  aroused.  Upon 
seeing  blood,  men  are  liable  to  think  that  they  have 
been  in  a  scrape  of  some  kind,  or  that  they  have  been 
attacked,  and  you  may  have  a  fight  on  your  hands.  If 
you  try  to  have  them  spit  before  they  are  sufficiently 
awake,  they  are  liable  to  spit  in  your  face,  or  on  the 
walls  or  the  floor,  or  anywhere.  Others,  being  fright- 
ened when  they  go  to  sleep  and  feeling  that  they  may 
never  wake  up,  imagine  when  you  disturb  them  that 
you  are  trying  to  resuscitate  them.     Second,  it  predis- 


General  Ancesthetics  in  Dentistry.  89 

poses  to  nausea.  I  believe  that  nearly  all  the  nausea 
accompanying  nitrous  oxid  gas  or  somnoform,  the 
clothing  being  properly  arranged,  is  the  result  of  rais- 
ing patients  up  too  soon  to  get  them  to  expectorate. 

In  larger  extraction  cases,  by  keeping  the  mouth- 
prop  in  place  the  blood  can  be  sponged  from  the  mouth 
as  in  any  other  surgical  operation.  When  used  in  this 
way,  do  not  fold  the  napkin,  but  use  it  as  a  sponge. 

The  modern  dental  chair  is  responsible  for  many 
anassthetic  failures.  At  least,  that  has  been  my  experi- 
ence. I  have  tried  nearly  all  chairs  that  have  been  on 
the  market  the  past  twenty-five  years,  and,  while  the 
old  Archer  has"  its  faults,  nevertheless  it  is  superior, 
as  an  anaesthetic  extracting-chair,  to  all  other  dental 
chairs,  when  nitrous  oxid,  ethyl  chloride  or  somnoform 
are  to  be  used.  The  old  wooden  Archer  chair  with  the 
detachable  foot-rest  is  the  chair  with  which  I  have 
been  most  successful.  This  is  a  surprising  statement, 
but  a  trial  is  convincing.  I  have  an  old  Archer  and 
also  one  of  the  most  modern  of  chairs  in  my  office. 
Occasionally,  to  hurry  matters  when  the  Archer  is  in 
use,  I  slip  a  patient  into  the  modern  chair,  to  make  an 
extraction,  and  nearly  always  promise  myself  that  I 
will  never  do  so  again.  The  difference  in  the  behavior 
of  the  patient  is  very  evident.  In  the  modern  chair,  the 
patient  places  his  feet  on  the  foot-rest  and  braces  him- 
self, pushing  backward.  This  pushing  with  the  feet 
causes  the  chest  to  rise  interfering  with  the  inhaler; 
pushing  harder,  the  head-rest  is  forced  to  one  side, 
or  the  head  slides  out  of  the  head-rest,  and  you  have  to 
substitute  vour  left  arm  as  a  head-rest.     I  have  had 


90  General  Ancesiketic's  in.  Dentistry. ^ 

patients  force  themselves  backwards  till  their  heads 
and  shoulders  were  beyond  the  chair  and  have  ex- 
tracted  in   that  position  many  times. 

.  In  the  modern  chair,  frequently,  when  just^  about 
to  extract  or  while  extracting,  one  of  the  levers  will  be 
touched  accidentally  by  the  arm  or  chest  or  by  the 
assistant,  the  head  falls  to  one  side,  one  of  the-  most 
annoying  things  that  can  happen.  I  have  ,  broken 
under  nitrous  oxid  angesthesia  the  foot-rest  of  two  S. 
S.  W.  chairs,  and  the  back  of  a  Morrison  chair,  from 
force  exerted  by  the  patient,  while  extracting  teeth. 
.  ;  The  old  Archer  has  a  detached  foot-rest  on  rollers. 
When  the  patient  begins  to  push,  the  fpot-rest  rolls 
forward,  and  the  legs  stand  out  straight  and  rigid  and 
the- patient  is  perfectly  helpless.  The  head-rest  is  se- 
cured by  a  thumb  screw  and  there  is  no  danger  of  its 
being  released.  ■  The- objection  to  the  Archer  is  that 
it  is  too  high  for  some  teeth.  This  objection  is  easily 
rjsmedied  by  standing  on  a  foot-stool  or  box  made  for 
tliat  purpose.  Next  in  preference  is  the  Morrison  chair. 
The- foot-rest  of  the  Morrison  :Chair  is  so  constructed 
that  the  part  on  which  the  heels  rest  when  the  legs  are 
extended,  the  piece  against  which  the  patient  Vk^ould 
press  when  bracing,  can  easily  be  detached  and  left 
off.  The  Morrison  then  becomes  an  .excellent  .chair 
for  extracting  teeth  under  nitrous  oxid,- ethyl. chloride 
and  somnoform  anaesthesia.  .•.,,••..,.    ■.■ 

,..,  Not  onlv  does  the  head-rest  yield  by , the. .force, ex- 
erted when  extracting  in  a  modern  deatal  chair,J!)ut  it 
js.  no,  unusual  occurrence  for.  -the  back  to  give  away 
when  the  patient  is  heavy  or  powerfully  built.     These 


General  Ancesiheiics  in  Dentistry.  9.1' 

accidents  of  the  chair  are  perplexing  in  the  extreme, 
and  are  responsible,  I  believe,  for  at  least  fifty  per  cent, 
of  the  failures  under  the  agents  mentioned  when  ad- 
ministered for  tooth  extraction. 

In  this  lecture  I  have  taken  into  consideration  a 
number  of  little  things,  the  things  that  are  either  over- 
looked by  most  operators  or  deemed  unimportant,  or 
too  trivial  to  put  into  practice,  but  it  is  strict  attention 
to  these  small  things  and  following  out  such  details 
that  makes  my  anaesthetic  work  more  successful  thaniri 
former  years. 


.-.frb 


92  General  Ancesthetics  in  Dentistry. 


LECTURE  VIII. 
Relative  Safety  of  General  Anaesthetics. 

Nitrous  oxid  and  oxygen  is  considered  the  safest  and 
chloroform  the  most  dangerous  of  anaesthetic  agents 
in  general  use.  I  could  quote  pages  of  statistics  to 
show  the  percentage  of  deaths  that  occur  during  anses- 
tliesia,  all  by  recognized  authorities,  but  it  would  be 
a  loss  of  time  and  of  no  value  whatever.  There  is  an 
old  saying,  "You  can  find  what  you  look  for,"  and  this 
is  more  than  true  when  you  undertake  to  establish  the 
relative  safety  of  anaesthetics  by  statistics.  Figures 
may  not  lie,  but  you  can  juggle  them  to  suit  your  pur- 
pose, just  as  you  can  distort  the  truths  of  the  Bible 
if  you  so  wish.  The  following  illustration  is  not  logi- 
cal or  true,  but  Scriptural :  "Judas  went  out  and  hanged 
himself";  "go  thou  and  do  likewise,"  "and  whatsoever 
thou  doest,  do  quickly." 

The  author  who  prints  statistics  to  prove  that  one 
death  occurs  in  every  thousand  administrations  of 
chloroform  may  be  set  down  as  one  partial  to  ether. 

Another  man  is  just  as  positive  that  the  average 
fatality  with  chloroform  is  not  more  than  one  in  four 
thousand.  Wood,  in  the  twelfth  edition  of  his  "Thera- 
peutics," says  the  average  mortality  is  one  death  in 
seven  hundred  thousand  administrations  of  NgO,  while 


General  Anaslhctics  in   Deniisiry-  93 

a  Xew  York  writer  maintains  there  is  l^ut  one  deatli  in 
one  million  administrations  of  N^O.  A  Chicago  man, 
a  somnoform  disciple,  has  recently  stated  that  he  is 
positiA'e  there  is  one  death  in  every  twenty-five  thou- 
sand administrations  of  XoO.  Luke  says  there  have 
been  onlv  thirty-five  deaths,  all  told,  during  NoO  anaes- 
thesia. This  Xew  York  average  is  made  from  statis- 
tics of  X'oC)  administered  in  Xew  York  City,  covering 
a  period  of  ten  years,  and  looks  good  on  the  surface ; 
but  I  am  suspicious  that  this  writer  is  as  enthusiastic 
an  X'oO  man  as  the  Chicagoan  is  a  somnoform  enthusi- 
ast. According  to  the  X'^ew  York  statement,  it  is 
safer  "to  take""  X\.0  than  to  cross  Broadway  or  Fifth 
Avenue;  than  to  play  foot-ball  or  ride  on  the  elevated 
raihvay;  to  attend  the  theater  or  go  slumming. 

Think  of  it — only  one  death  in  a  million  administra- 
tions of  X'oO! 

The  average  of  mortality  is  greater  among  men 
delivering  a  sermon  or  making  a  prayer,  eating  a  meal 
or  taking  an  afternoon  nap,  attending  a  banquet  or  in- 
dulging in  a  stroll. 

E\"en  \^•ith  a  showing  of  this  kind  for  X'^O,  almost 
beyond  belief,  the  somnoform  enthusiast  is  setting  up 
the  claim,  in  good  faith,  that  somnoform  is  the  safest 
of  all  ansesthetics.  It  almost  makes  one  feel  that  we 
would  l)e  safer  in  an  atmosphere  of  X'oO  and  somno- 
form than  to  inhale  the  poisonous,  germ-bearing  air  of 
our  offices. 

1  \\\\\  take  the  liberty,  however,  to  quote  a  few- 
statistics  to  make  clearer  my  position. 


94  General  Ancesihetics  in  Deniisiry. 

Statistics  collected  by  Julliard: — 

Administrations. 

Chloroform 524,507       16  deaths— 1  in     3,258 

Ether 314,738       21  deaths— 1  in  14,987 

By  Ormsby: — 

Administrations. 

Chloroform. 152,260       53  deaths— 1   in     2,873 

Ether 92,815         4  deaths— 1   in  23,204 

St.  Bartholomew's  Horpital: — 

Administrations. 

Chloroform 19,526       13  deaths— 1  in     1,502 

Ether ; 8,491         3  deaths— 1  in     2.830 

N2O  and  ether.  .    .  .    12,941         1  death  —1  in  12,941 

By  Luke : — 

NoO 1  death  in  100,000  administrations 

Ethyl  chloride.  .   ..1  death  in  12,000  administrations 

Ether 1  death  in  10,000  administrations 

A.  C.  E.  and  C.  E.l  death  in  7,500  administrations 

Chloroform,  at  least  1  death  in  1,000  administrations 

Pastre  states  that  during-  the  Crimean  War  only  1 
death  occurred  in  10,000  administrations  of  chloroform. 

There  is  no  satisfaction  to  a  seeker  of  truth  in  ^uch 
an  array  of  figures  as  quoted  above.  St.  Bartholo- 
mew's -lospital  statistics  show  that  there  is  an  average 
of  one  death  in  every  2,830  administrations  of  ether, 
while  Ormsby  shows  there  is  but  one  death  in  23,204 
administrations  of  ether.  Again,  Luke  says  there  is 
one  death,  at  least  in  every   1,000  administrations  of 


General  Anceslhetics  in  Dentislry.  95 

chloroform,  while  Julliard  maintains  there  is  but  one 
mortality  in  every  3,258  administrations  of  chloroform. 

If  the  estimate  is  correct  in  regard  to  one  death  in 
1,000,000  administrations  of  NoO,  no  dental  surgeon 
need  lay  avv^ake  nights  worrying  over  mortalities.  If 
an  operator  should  administer  NoO  ten  times  per  day, 
including  Sundays  and  holidays,  and  took  no  vacations, 
he  would  be  entitled  to  only  one  mortality  in  274  years 
of  practice. 

If  we  should  take  all  the  statistics  that  have  been 
collected,  and  strike  an  average  showing  the  ratio  of 
deaths  to  the  number  of  times  a  given  anaesthetic  has 
been  administered,  it  would  have  no  bearing  on  the 
subject  whatever.  These  statistics  are  made  to  deter- 
mine the  percentage  of  deaths  during  anaesthesia,  and 
have  nothing  to  do  with  the  relative  safety  of  anaes- 
thetics. What  we  want  to  know  is  the  percentage  of 
deaths  caused  by  anaesthetics.  It  is  estimated  that 
105,000  people  die  every  day  of  the  year.  We  know 
that,  in  cases  of  injury,  where  men  are  so  horribly 
mangled  that  there  is  not  the  least  hope  of  recovery, 
for  humane  reasons  they  are  hurried  to  a  hospital, 
aniesthetized  and  operated  upon,  die  during  anaesthesia 
from  their  injuries,  and  these  cases  are  all  set  down  a? 
deaths  under  anaesthetics.  Many  die  on  the  operating 
table  under  anaesthetics,  it  is  true,  but  die  from  disease, 
and  these  deaths  help  to  make  up  the  average.  Many 
die  at  the  close  of  a  long  operation  from  exhaustion; 
many  more  die  from  shock,  as  the  result  of  operating 
too  soon  or  too  long;  others  die  at  the  very  beginning 
of  the  operation  from  spasm  of  the  glottis,  the  anaes- 


96  General  Anccsthetics  m  Dentistry. 

thetic,  improperly  administered ;  others  die  from  an 
overdose  of  ansesthetic,  others  from  collection  of  mu- 
cus, blood,  vomit,  etc.,  accumulating  in  the  pharynx, 
and  others  die  from  apoplexy,  heart  failure,  etc.,  just 
as  they  would  have  died  had  they  not  been  anaesthet- 
ized. AAHien  we  take  into  consideration  that  medical 
men  and  dental  practitioners,  almost  all  of  them,  ex- 
cept a  few  who  are  fortunate  enough  to  become  in- 
ternes, must  learn  to  administer  ansesthetics  them- 
selves after  graduating,  it  is  surprising  that  there  are 
not  many,  many,  many  more  mortalities  during  anaes- 
thesia. It  is  said  that  "an  oculist  spoils  a  hatful  of 
eyes  learning  to  do  a  cataract  operation."  If  this  be 
true,  Providence  must  indeed  be  kind  to  young  men 
in  their  early  anaesthetic  career. 

The  medical  student  of  to-day  does  not  have  as 
good  an  opportunity  to  familiarize  himself  with  the 
administration  of  anaesthetics  as  students  of  twenty 
years  ago.  Formerly  anaesthetics  at  surgical  clinics 
were  administered  in  the  operating-room  in  the  pres- 
ence of  the  class;  now  they  are  administered  in  an 
adjoining  room  and  wheeled  into  the  pit,  ready  for 
the  operation. 

Yes,  chloroform  is  tlie  most  dangerous  of  all  anaes- 
thetics, or  rather,  we  have  more  deaths  from  chloro- 
form than  from  any  other  ancesthetic.  Chloroform  is 
not  so  much  to  blame,  however,  as  the  administrator. 
When  we  understand  chloroform  better,  and  avail  our- 
selves of  sane  methods  of  administering  chloroform, 
the  death  rate  will  not  be  so  high. 

Jt    is    impossible    to    ascertain    the    percentage    of 


General  Anccsthetics  in  Dentistry.  97 

deaths  caused  by  anaesthetics.  I  am  satisfied  in  my 
own  mind  that  the  percentage  of  deaths  caused  by 
anaesthetics  is  very  small  as  compared  to  the  percent- 
age of  deaths  that  occur  during-  anaesthesia.  AA'hen  the 
m.edical  schools  require  as  thorough  training  in  anaes- 
thetics as  they  do  in  anatomy,  histology,  pathology 
and  chemistry,  and  the  dental  schools  establish  an 
anaesthetic  clinic,  as  they  have  done  in  operative  and 
prosthetic  dentistry,  I  believe  that  in  ten  years  the 
mortality  undef-  anaesthetics  can  be  reduced  50  per  cent. 

The  safest  of  all  general  anaesthetics  is  a  combina- 
tion of  nitrous  oxid  and  oxygen.  No  death  with  this 
combination  has  ever  been  reported.  Not  onh^  is  it 
the  safest,  but  likewise  the  most  pleasant  of  all  anaes- 
thetics to  inhale,  and  the  patient  recovers  almost  the 
instant  the  inhaler  is  removed  from  the  face.  This 
anaesthetic  is  applicable  not  only  to  brief  and  unimpor- 
tant operations,  but  has  been  used  on  occasions  in  the 
gravest  of  conditions,  Avhen  all  other  anaesthetics  were 
contra-indicated.  Not  many  months  ago  Dr.  Teters, 
of  Cleveland,  succeeded  in  keeping  a  patient  auc-esthet- 
ized  for  nearly  three  hours  with  nitrous  oxid  and  oxy- 
gen. On  this  occasion  the  patient  inhaled  600  gallons 
of  nitrous  oxid,  and  if  I  remember  correctly,  80  gallons 
of  oxygen.  While  this  combination  is  the  safest  of 
all  anaesthetics,  it  is  the  most  difficult  of  all  to  admin- 
ister. 

The  next  in  order  of  safety  is  nitrous  oxid,  and  next 
in  order  of  difficult  administration  is  nitrous  oxid.  It 
IS  unfortunate  that  the  most  pleasant  anaesthetics  to 
take,   and    witlnnit   (loul)t    the   least   dangerous,   should 


98  General  Ancesihetics  in  Dentistry. 

be  the  most  difficult  to  administer.  Dr.  Laird  W. 
Nevius,  of  Chicago,  has  administered  NoO  nearly 
100,000  times  without  an  accident.  Could  these  anjes- 
thetics  be  handled  as  easily  as  ether  or  chloroform, 
fvithout  special  apparatus  and  clumsy  cylinders,  there 
would  be  no  need  of  the  more  dangerous  aucxsthetics 
now  in  common  use.  It  was  a  triumph  worth  record- 
ing when  the  manufacturers  learned  to  liquify  nitrous 
oxid  and  place  it  in  cylinders  for  our  convenience.  If 
the  manufacturer  would  go  one  step  further,  and  do 
for  us  what  has  been  done  with  ethyl  chloride  and 
somnoform,  in  the  way  of  putting  it  in  a  convenient 
form  for  use,  it  would  be  a  benediction  second  to  the 
discovery  of  anaesthesia. 

Somnoform,  the  most  beautiful  of  all  anaesthetics 
in  its  action,  the  easiest  of  all  anaesthetics  to  adminis- 
ter, the  most  reliable  of  all  anaesthetics  for  brief  oper- 
ations, so  far  as  the  record  of  deaths  during  anaesthesia 
shows,  as  safe  as  nitrous  oxid.  Properly  adminis- 
tered, somnofoYm  has  no  rival ;  for  efficiency,  it  stands 
alone  in  a  class  of  its  own.  You  can  come  nearer  get- 
ting a  perfect  result  every  time  you  make  an  adminis- 
tration, with  somnoform,  than  you  can  with  any  other 
antesthetic  with  which  I  am  acquainted.  In  t!ie  hands 
of  the  skillful,  intelligent  anaesthetist,  the  careful  pains- 
taking anaesthetist,  as  safe  as  the  safest  anaesthetic, 
but  in  the  hands  of  the  careless,  ignorant,  reckless 
anaesthetist  accidents  may  arise  from  its  improper 
cidministration. 

While  there  have  been  no  deaths  from  nitrous  oxid 
and  oxygen,  and  only  thirty-five  deaths  during  or  as  the 


[General  AncEsihetics  in  Dentistry.  99 

result  of  nitrous  oxid,  in  sixty  years  of  use,  and  the 
percentage  of  deaths  from  somnoform  no  greater  than 
that  of  nitrous  oxid,  yet  there  is  this  to  be  said  about 
somnoform :  you  might  push  it  far  enough  to  result  in 
an  accident  without  the  patient  showing  much  evidence 
that  anything  was  wrong ;  while  with  nitrous  oxid  the 
patient's  appearance  and  actions  would  be  such  as  to 
alarm  and  frighten  the  anassthetist,  thus  giving  ample 
warning,  as  a  dangerous  condition  was  approached. 
You  could  tie  a  patient  down,  and  smother  him  to 
death  with  any  of  the  ansesthetics,  if  you  held  them 
over  his  nose  and  mouth  long  enough,  excluding  all  air, 
but  you  must  remember  always,  it  is  not  what  an  anaes- 
thetic can  do,  ad  libitum,  but  what  it  does  when  prop- 
erly and  skillfully  administered. 

Next  in  order  of  safety  may  be  placed  ether.  Ether 
may  be  emplo3^ed  for  brief  operations,  and  is  usually 
selected  for  prolonged  surgical  operations.  The  fact 
that  the  percentage  of  deaths  during  or  as  the  result 
of  ether  administration  has  been  materially  lessened 
with  improved  methods,  shows  conclusively  that  the 
larger  percentage  of  deaths  in  the  past  are  chargeable 
to  the  anaesthetist  rather  than  the  anaesthetic. 

A  prominent  surgeon  told  me  recently  that  since 
the  drop  method  of  administering  ether  had  come  into 
such  general  use  he  did  not  think  there  was  more  than 
one  ether  death  in  20,000  administrations.  Hewitt, 
from  a  careful  analysis  of  the  statistics  collected  by 
him,  argues  that  ether  is  about  seven  times  as  safe  as 
chloroform.  Ether  is  certainly  gaining  in  favor  over 
chloroform,  and  its  administration  is  no  longer  consid- 


100  General  Amesilietics  in  DcnlisUy. 

creel  a  dangerous  procedure.  Indeed,  in  the  hands  of 
a  competent  anaesthetist,  the  risk  of  ether  anaesthetic 
accidents  is  infinitesimal. 

Ethyl  chloride  is  very  popular  just  now  in  England, 
on  the  Continent,  and  in  our  Eastern  cities.  As  to  the 
matter  of  safetv,  this  anaesthetic  may  be  classed  be- 
tween ether  and  chloroform.  It  is  employed  mostly 
for  the  induction  of  brief  aniesthesia,  and  frequently  as 
preliminary  to  ether.  Luke  gives  this  anaesthetic  a 
death  rate  of  one  in  twelve  thousand.  It  is  a  peculiar 
circumstance  that  so  many  deaths  should  occur  under 
ethvl  chloride,  while  somnoform,  which  is  sixty  per 
cent,  ethyl  chloride,  is  amazingly  safe.  I  think  in  time 
im]5roved  methods  of  administering  ethyl  chloride  will 
greatly  reduce  the  death  rate. 

Chloroform  is  the  most  dangerous  of  all  ansesthetics, 
or  rather  the  percentage  of  deaths  under  chloroform  is 
higher  than  that  of  any  ana?sthetic  in  general  use. 
Chloroform,  however,  is  not  so  nuicli  to  blame,  as  the 
careless,  reckless,  almost  criminal  manner  in  which 
it  is  administered.  A  more  intimate  knowledge  of 
•chloroform,  and  a  better  understanding  of  its  physio- 
logical action,  along  with  improved  methods  of  admin- 
istration, will  increase  its  efficiency  and  decrease  the 
percentage  of  mortality. 

The  fact  that  some  anaesthetists  confine  themselves 
to  the  use  of  chloroform  exclusively  and  have  never 
witnessed  a  death  during  or  as  the  result  of  chloro- 
form anccsthesia  argues  that  the  manner  in  which  ciilo- 
roform  is  administered  has  much  to  do  with  the  suc- 
cess or  failure  attained.     All   (ir  nearly  all  deaths  that 


General  Ancesthetics  in  Dentistry.  lUl 

occur  during  the  first  two  or  three  minutes  of  chloro- 
form administration,  are  caused  from  fright,  or  because 
the  vapor  is  too  heavil}'  laden  with  the  anipsthetic. 
Those  deaths  that  occur  as  the  result  of  shock,  because 
the  patient  is  not  sufficiently  aufesthetized,  are  not 
chargeable  to  chloroform.  Deaths  happen  under  chlo- 
roform very  suddenly  at  times,  the  pulse  giving  no  pre- 
liminary Avarning,  the  breathing  normal,  and  the  patient 
evidently  doing  well,  but  these  conditions  arise  when 
a  large  nerve  is  severed,  or  the  vital  organs  handled  or 
squeezed,  or  the  vagus  is  dragged  or  stretched.  Hew- 
itt says :  "It  is  by  no  means  improbable  that  some  of  the 
sudden  deaths  which  have  occurred  under  anaesthetics 
and  which  have  been  ascribed  to  their  action  have  in 
reality  arisen  from  cardiac  or  pulmonary  embolism. 

It  must  be  remembered  that  in  addition  to  the 
causes  already  enumerated  that  produce  or  lead  up  to 
death  during  chloroform  induction  or  narcosis,  that 
chloroform,  per  se,  is  a  protoplasmic  poison,  and,  when 
a  sufficient  amount  has  accumulated  in  the  sys- 
tem, shock  may  arise  from  this  cause.  This  is  not 
probable  if  the  anaesthetist  Avill  constantly  keep  in  mind 
that  two  per  cent,  of  chloroform  is  sufficient  to  anaes- 
thetize a  patient  and  one  per  cent,  is  all  that  is  required 
to  maintain  anaesthesia. 

As  unusual  care  must  be  exercised  in  administering 
chloroform,  and  as  most  physicians  are  more  familiar 
with  ether,  it  is  safer  to  employ  ether  for  all  cases  of 
extracting  teeth,  in  which  the  choice  lies  between  ether 
and  chloroform,  whenever  the  extracting  is  to  be  done 
in  a  dental  office. 


102  General  Ancesihetics  in  Dentistry. 

It  is  utterly  impossible  to  ascertain  the  percentage 
of  deaths  caused  by  ancesthetics,  the  best  we  can  do  is 
to  determine  the  number  of  deaths  that  occur  during 
angesthesia.  Hundreds  of  deaths  are  ascribed  to  anaes- 
thetics, and  they  go  down  in  history  as  anesthetic 
deaths,  when  the  anassthetic  was  in  no  way  responsible. 
It  is  customary  for  some  physicians,  and  even  some 
hospitals,  to  ascribe  all  or  nearly  all  deaths  that  follow 
a  surgical  operation,  to  shock,  the  result  of  the  anges- 
thetic.  No  matter  how  skilful  a  surgeon  may  be,  and 
no  matter  what  may  be  the  real  cause  of  death  during 
ancESthesia  or  following  the  operation,  it  sounds  better 
to  the  family  of  the  deceased,  to  the  public  and  even 
to  the  surgeon  himself  to  have  it  said  that  the  patient 
died  from  the  effects  of  the  anaesthetic  than  that  he 
died  as  the  result  of  the  operation.  When  the  report 
is  spread  abroad  that  the  patient  died  from  the  effect 
of  the  anaesthetic,  the  case  is  closed.  When  it  is  whis- 
pered around  that  the  patient  died  from  the  operation, 
the  inference  is  that  the  surgeon  was  at  fault,  and  some 
one  has  blundered.  This  is  a  factor  that  is  to  be  taken 
into  consideration,  when  a  death  occurs  during  an 
operation,  and  for  this  reason  we  will  never  be  able  to 
ascertain  accurately  the  number  of  deaths  that  are 
caused  by  the  anaesthetic  agent  per  se. 


General  Ancesihetics  iu  Dentistry.  1C3 


LECTURE  IX. 

Nitrous  Oxid  Gas. 

Priestly  discovered  nitrous  oxid  gas,  Sir  Humphry 
Davy  recognized  its  pain-relieving  qualities,  Horace 
Wells  discovered  its  anaesthetic  properties,  Colton  in- 
duced with  it  the  first  surgical  anaesthesia,  and  Dr.  E. 
Andrews,  of  Chicago,  was  the  first  to  add  oxygen  to 
prolong  nitrous  oxid  anaesthesia. 

A  long  and  bitter  controversy  arose  as  to  whom  was 
due  the  credit  of  discovering  surgical  annssthesia.  Dr. 
Burton  Lee  Thorpe,  in  his  biographical  sketch  entitled 
"Horace  Wells,  Dentist,  Humanity's  Greatest  Bene- 
factor, the  Discoverer  of  Surgical  Anaesthesia,"  in  the 
Dental  Brief,  for  July  and  August,  '06,  has  settled  that 
question  forever. 

In  the  year  1844,  a  Dr.  Colton  delivered  a  popular 
course  of  lectures  on  chemistry,  and  in  the  month  of 
December  happened  to  be  in  Hartford,  Conn.  He  con- 
ducted his  lecture  course  on  the  same  plan  as  men  have 
been  doing  of  late  years  on  hypnotism.  On  this  par- 
ticular occasion  nitrous  oxid  was  discussed  and  mem- 
bers of  the  audience  invited  to  the  stage  to  inhale 
nitrous  oxid  to  the  point  of  stimulation  to  amuse  those 
present.  Dr.  Horace  Wells  was  present  and  with 
others  took  his  place  on  the  platform.     He  inhaled  the 


104  General  Ancestheti^s  in  Deniisiry. 

"laughing  gas,"  as  it  was  then  called,  and  was  pleased 
with  the  sensation  produced. 

The  exciting  incident  to  him  at  the  evening's  en- 
tertainment was  when  ^Ir.  Samuel  A.  Cooley,  a  Avell- 
known  Hartford  man,  gave  a  lively  exhibition  of  the 
effects  of  the  gas  by  running  and  jumping  about  and 
falling,  striking  his  legs  against  the  wooden  settees, 
and  acting  apparently  perfectly  unconscious  of  possible 
danger.  After  the  effects  of  the  gas  had  passed  off,  Dr. 
AA'ells  asked  him  if  he  was  hurt,  and  he  replied  that  he 
did  not  know  it  at  the  time,  but  on  looking  at  his  legs, 
found  them  bleeding  from  the  injuries  received.  Dr. 
A\>lls,  turning  to  Mr.  David  Clark  said,  "I  believe  a 
man,  taking  gas,  could  have  a  tooth  extracted,  or  a 
limb  amputated,  and  not  feel  the  pain."  (Thorpe.) 

The  events  of  the  evening"  so  impressed  Dr.  Wells, 
that,  after  the  lecture,  he  went  to  the  home  of  Dr. 
Riggs,  of  pyorrhoea  alveolaris  fame,  to  discuss  the 
matter  with  him,  and  decided  that  he  would  inhale  the 
gas  on  the  morrow  if  Dr.  Riggs  would  operate  for  him. 
Next  morning,  at  the  office  of  Dr.  Riggs,  Colton  ad- 
ministered the  gas.  Wells  inhaled  it,  and  in  the  presence 
of  Cooley,  Dr.  Riggs  extracted  an  upper  third  molar, 
Wells  exclaiming  after  remaining  unconscious  a  few 
seconds,  "I  did  not  feel  so  much  as  the  prick  of  a  pin — 
a  new  era  in  tooth  pulling."     (Thorpe.) 

Twenty-five  years  after  Priestly  discovered  nitrous 
oxid  gas,  Sir  Humphry  Davy  suggested  that  it  might 
be  used  for  relieving  pain;  but  forty-four  years  again 
elapsed  l)eforc  Wells  flcmonstratcd  this  prophesy,  Dec. 
nth.  1S44.       ' 


General  Ancesthetics  in  Deniistry.  105 

"(  )n  that  fb}'  modern  anipsthesia  was  given  to  the 
world,  and  nitrous  oxid  gas  proved  to  be  a  blessing  to 
suffering  humanit}-  and  the  forerunner  of  all  other 
anaesthetics."      (Thorpe.) 

I  know  not  what  name  was  used  in  the  beginning 
to  describe  this  state  or  condition  we  now  call  "rinKS- 
thesia."  Two  years  later,  when  ^Morton,  another  dentist, 
discovered  the  ann?sthetic  properties  of  ether,  Dr.  Oli- 
ver Wendell  Holmes  wrote  him  :  ''Everybody  wants  to 
have  a  hand  in  the  great  discovery.  All  I  will  do  is  to 
give  you  a  hint  or  two  as  to  names  or  the  name  to  be 
applied  to  the  state  produced  and  to  the  agent.  The 
state  should,  I  think,  be  called  'anaesthesia.'  The  ad- 
jective will  be  'anaesthetic'  Thus  we  might  say,  'the 
state  of  anaesthesia,  or  the  anaesthetic  state.'  "  (Thorpe.") 

Nitrous  oxid  is  a  colorless,  transparent  gas  of 
sweetish  odor  and  taste,  non-irritating  to  the  tissues, 
and  not  unpleasant  to  inhale.  Nitrous  oxid  gas  is  not 
a  poison  in  itself  nor  does  it  form  poisonous  combina- 
tions or  deleterious  chemical  relations  with  the  con- 
stituents of  the  blood.  It  does  not  decompose  during 
its  passage  through  the  circulatory  system,  the  body 
temperature  not  being  sufficient  to  cause  disintegration. 

3ilanv  theories  have  been  advanced  to  explain  the 
aucxsthetic  action  of  nitrous  oxid.  At  first,  it  was 
thought  that  hyper-oxygenation  of  the  blood,  the  result 
of  the  oxygen  and  nitrogen  separating  and  the  oxygen 
being  absorbed  by  the  blood,  was  the  cause,  resulting 
in  an  internal  asphyxia.  Later,  Duret  and  Blanche 
maintained  that  the  an.nesthetic  eft'ect  of  nitrous  oxid 
depended  on  an  insnfficicnt  amount  of  oxygen  rather 


106  General  Ancesthetics  in  Dentistry. 

than  a  superabundance.  It  was  these  views  that  gave 
rise  to  the  asphyxial  theory;  namely,  that  one  who  had 
inhaled  a  sufficient  amount  of  nitrous  oxid  to  produce 
ansesthesia  was  asphyxiated,  and  not  anaesthetized. 
Andrews,  of  Chicago,  about  this  time,  was  adding  oxy- 
gen to  nitrons  oxid  to  prolong  the  anaesthetic  effect, 
producing  by  the  use  of  this  mixture  a  non-asphyxial 
ansesthesia.  A  non-asphyxial  anjEsthesia  can  also  be 
obtained  by  the  addition  of  air  to  nitrous  oxid  gas. 
Ansesthesia  can  be  maintained  for  hours  at  a  time  by 
the  addition  of  either  oxygen  or  air,  without  the  least 
asphyxia,  proving  conclusively  that  nitrous  oxid  pos- 
sesses anaesthetic  properties  of  its  own. 

"The  initial  sensations  under  nitrous  oxid  are  of  an 
agreeable  and  stimulating  character,  almost  identical 
with  those  of  ether  and  chloroform;  and,  when  non- 
asphyxial  and  deep  nitrous  oxid  ansesthesia  is  estab- 
lished, this  ansesthesia  is  similar,  in  its  main  features, 
to  that  produced  by  other  anaesthetics.  Were  nitrous 
oxid  ansesthesia  the  result  of  simple  oxygen  depriva- 
tion, we  should  not  expect  the  initial  sensations  pro- 
duced by  the  inhalation  to  be  of  an  exhilerating  char- 
acter. Nitrous  oxid  has,  in  fact,  quite  as  great  a  claim 
as  chloroform  to  be  considered  a  general  ansesthetic." 
(Hewitt.) 

A  mixture  of  nitrous  oxid  and  oxygen  can  be  in- 
haled indefinitely,  but  this  is  not  true  of  nitrous  oxid 
alone.  Nitrous  oxid  does  not  support  animal  or  vege- 
table life,  and  it  is  not  safe  to  administer  it  even  as  long 
as  one  minute  if  all  air  be  excluded.  "In  the  case  of 
man,   the  average  inhalation  period  is  56  seconds;  at 


General  Ancesthetics  in  Dentistry  107 

the  end  of  that  time,  fresh  oxygen  must  be  admitted 
or  permanent  asphyxia  will  result."  (Hewitt.) 

Claude  Martin,  of  Lyons,  administered  a  mixture 
of  nitrous  oxid  and  oxygen  to  a  dog  for  three  consecu- 
tive days,  and  the  dog  was  none  the  worse.  Only  fif- 
teen per  cent,  of  oxygen  was  used. 

When  animals  are  killed  by  pure  nitrous  oxid  gas, 
an  examination  shows  the  right  cavity  of  the  heart  to 
be  full  of  blood  and  the  left  cavity  empty ;  the  same 
condition  is  found  when  animals  die  of  asphyxia.  Post- 
mortem examinations  of  patients  who  have  died  under 
nitrous  oxid,  as  reported  by  Hewitt,  when  asphyxia 
has  been  assigned  as  the  cause,  have  also  disclosed  the 
fact  that  the  right  cavity  of  the  heart  was  full  and  the 
left  empty.  Johnson  believes  that  however  asphyxia  is 
induced — whether  by  nitrous  oxid,  by  nitrogen  or  by 
paralyzing  respiration  by  curare — the  same  effects 
follow. 

It  is  not  difficult  to  understand,  as  nitrous  oxid  pro- 
duces asphyxia  if  air  is  excluded,  and  the  post-mortem 
examination  of  an  animal  that  has  died  from  nitrous 
oxid  shows  the  same  pathological  condition  of  the 
heart  as  is  found  when  death  results  from  asphyxia, 
that  nitrous  oxid  should  have  been  classed  as  an  as- 
phyxiating agent  rather  than  an  anaesthetic  agent.  It 
is  generally  conceded  that  nitrous  oxid  is  a  heart  stim- 
ulant and  causes  increased  blood  pressure. 

Kemp  thinks  that  contraction  of  the  renal  vessels 
takes  place,  resulting  in  a  decreased  urinary  secretion ; 
also  that  albuminaria  is  produced  in  a  slight  degi'ce  in 
complete  narcosis. 


108 


General  Ancesthctics  in  Dentistry. 


An  overdose  of  nitrous  oxid  produces  death  in 
nearly  all  cases  from  asphyxiation,  the  heart  in  some 
cases  continuing-  to  beat  for  a  period  of  several  min- 
utes. Hev\dtt  thinks  the  immediate  cause  of  respira- 
torv  arrest  is  usuallv  muscular  sDasm. 


Apparatus. 

Nitrous  oxid  gas  is  made  by  heating  ammonia 
nitrate.  The  gas  thus  generated  passes  through  two 
or  three  wash  bottles  to  absorb  any  impurities  that  may 
be  present,  and  is  collected  in  a  large  tank  or  gaso- 
meter. 


This  cut  represents  a  porcelain-lined  iron  retort  for  generating 
nitrous  oxid.  Oxygen  can  also  be  generated  in  the  same  retort, 
but  not  at  the  same  time.  One  pound  of  nitrate  of  ammoniri  will 
make  about  thirty-two  gallons  of  nitrous  oxid  gas.  "One  pound 
of  'oxygen  compound'  will  make  about  thirty-five  gallons  of  oxy- 
gen."     fLennox  Chemical  Co.) 

In  an  early  day  it  Avas  customary  for  dentists  to 
manufacture  their  own  nitrous  oxid,  but  at  the  present 
time   only  the   extracting  specialists  and  those   using" 


The  S.  S.  White  Two-CyUnder  Apparatus 


110  General  Ancesthetics  in  Dentistry. 

gas  in  large  quantities  make  their  own  gas.  There 
are  obstacles  to  be  met  and  overcome  in  the  manufac- 
ture of  nitrous  oxid,  such  as  inability  to  obtain  the 
same  grade  of  ammonia  nitrate  each  time,  and  regulat- 
ing the  requisite  degree  of  heat  to  obtain  uniform  re- 
sults; for  these  reasons  and  other  annoyances,  even 
the  extracting  specialists  are  turning  to  the  wholesale 
manufacturers  for  their  supplies  of  this  anaesthetic 
agent. 

Farraday,  in  1823,  succeeded  in  liquifying  nitrous 
oxid  gas.  The  manufacturers  have  taken  advantage 
of  this  discovery  and  have  learned  how  to  condense 
nitrous  oxid.  This  is  done  under  immense  pressure 
at  a  low  temperature,  and,  in  order  to  confine  the  gas 
in  this  state,  heavy  steel  cylinders  are  used.  In  Eng- 
land cylinders  can  be  obtained  containing  twenty-five 
and  fifty  gallons  of  nitrous  oxid,  but  in  this  country 
one  hundred  gallons,  so  far  as  I  know,  is  the  minimum 
size,  but  it  can  also  be  obtained  in  two  hundred  and 
fifty  and  five  hundred-gallon  cylinders.  As  nitrous  oxid 
gas  does  not  deteriorate  with  age,  the  larger  cylinders 
are  more  convenient  for  dentists  remote  from  a  dental 
depot  who  have  to  pay  transportation  charges.  One 
feels  far  more  comfortable  with  the  larger  cylinders 
when  administering  nitrous  oxid  for  a  prolonged  sur- 
gical anaesthesia,  and  even  in  dental  practice  it  is  as- 
suring to  feel  that  there  is  sufficient  gas  for  the  opera- 
tion without  the  annoyance  of  changing  cylinders. 
Taking  into  consideration  the  transportation  charges 
and  the  loss  in  each  cylinder  when  the  gas  does  not 


General  Ancestheiics  in  Dentistry. 


Ill 


come  out  even,  one  five  hundred-gallon  cylinder  is  far 
more  economical  than  five  one  hundred-gallon  cylin- 
ders. 

In  the  earlier  manufacture  of  cylinders,  annoyance 


The  Improved  Clark  Gas  Apparatus 

and  inconvenience  was  caused  from  imperfect  valves. 
These  valves  would  permit  the  gas  to  escape  and 
sometimes  only  one  or  two  administrations  of  nitrous 
oxid  could  be  made  from  a  one  hundred-gallon  cylin- 


112 


General  ArKBsthetics  in  Dentistry. 


der.  It  is  embarrassing,  when  you  only  need  two  or 
three  more  inhalations  to  complete  an  anaesthesia,  to 
find  the  cylinder  exhausted,  which  is  supposed  to  be 
two-thirds  full. 


The  Teter  Apparatus. 


One  hundred  gallons  of  nitrous  oxid  should  weigh 
just  about  30  ounces.  Each  cylinder  has  marked  on  it 
or  on  a  tag  attached  to  it  the  weight  of  the  cylinder 
and  the  weight  of  the  gas.     It  is  a  good  plan  to  weigh 


General  Anccsthctics  in  Dentisiry. 


113 


the  cylinder  when  you  unbox  it  and  ascertain  if  there 
has  been  a  leakage  and  about  how  much. 

If  an  administration  has  not  been  made  for  some 
time  and  3rou  are  in  doubt  as  to  the  amount  of  nitrous 
oxid  that  should  be  in  the  cylinder,  it  is  better  to 
weigh  the  cylinder  than  take  the  risk  of  having  the  gas 


The  Teter  Nasal  Inhaler. 


a  little  short  of  enough  to  induce   the   desired  anaes- 
thesia. 

The  more  modern  appliances  ..ic  provided  with  two 
cylinders  so  arranged  that  you  can  switch  from  an 
empty  to  a  full  cylinder:  but  even  this  involves  a  loss 


114  General  Ancesihetics  in  Dentistry. 

of  time  and  division  of  attention  when  the  operator 
should  not  be  interrupted. 

The  matter  of  appliances  is  an  important  one.  There 
are  many  from  Avhich  to  select,  each  having  its  ad- 
vantages and  disadvantages.  For  the  administration 
of  nitrous  oxid  alone,  without  the  addition  of  oxygen, 
I  am  partial  to  the  small  gasometer,  such  as  the  S.  S. 
White,  Nevius  and  Long  appliances.  These  gaso- 
meters can  be  fitted  with  any  size  cylinder  you  wish 
from  one  hundred  to  five  hundred  gallons.  The  advant- 
ages are  these  :  You  release  the  gas  and  allow  it  to  pass 
into  the  gasometer  before  making  the  administration. 
In  the  gasometer  there  is  a  certain  amount  of  water 
which  of  necessity  is  of  the  same  temperature  as  the 
room,  and  this  warms  the  nitrous  oxid  which  is  an 
advantage  to  the  patient.  There  is  a  register  on  the 
gasometer  which  indicates  the  number  of  gallons  of 
gas  it  contains  and  you  know  the  amount  of  nitrous 
oxid  that  is  being  consumed.  As  the  patient  inhales, 
the  inner  barrel  settles  in  the  water,  its  weight  forcing 
the  gas  out  into  the  lungs,  and  in  poor  breathers  and 
shallow  breathers  this  is  quite  an  advantage.  Indeed, 
weights  can  be  placed  on  top  of  the  inner  barrel  and  ad- 
ditional force  exerted.  The  fact  that  you  can  provide 
sufficient  gas  before  administering  the  anaesthetic,  and 
not  have  to  fill  and  re-fill  the  rubber  bag,  is  quite  an 
advantage  if  the  patient  proves  to  be  an  excitable  one 
or  you  happen  to  have  a  poor  assistant.  If  I  were 
using  nitrous  uxid  alone  without  oxygen,  1  would  re- 
turn to  tin-  use  of  one  of  these  ofasometers. 


General  AncBsthetics  in  Dentistry.  115 

The  addition  of  oxygen  to  nitrous  oxid  for  the  pur- 
pose of  prolonging  anaesthesia  has  resulted  in  a  modifi- 
cation of  the  older  appliances  to  adjust  themselves  to 
the  new  condition.  Nitrous  oxid  without  the  addition 
of  oxygen  can  be-  used  in  all  the  appliances  to  which 
I  shall  call  attention  or  describe. 


116  General  Amesthetics  in  Dentistry. 


LECTURE  X. 
Nitrous  Oxid  Administration. 

For  the  sake  of  convenience,  we  will  discuss  this 
subject  in  the  following  order: 
First :       Nitrous  oxid  pure,  without  air. 
Second :  Nitrous  oxid  with  an  admixture  of  air. 
Third :     Nitrous  oxid  and  oxygen. 

There  is  only  one  anaesthetic  more  difficult  to  admin- 
ister than  nitrous  oxid ;  namely,  nitrous  oxid  and  oxy- 
gen. Too  much  apparatus  is  necessary  in  the  adminis- 
tration of  nitrous  oxid  to  make  it  popular,  and,  for  this 
reason,  it  will  never  be  as  universally  adopted  by  den- 
tists as  ether  and  chloroform  have  been  by  physicians. 
When  the  physician  operates,  he  simply  operates  and 
has  no  care  of  either  the  patient  or  the  anassthetic ;  but 
when  the  dentist  has  occasion  to  administer  nitrous 
oxid  he  performs  a  three-fold  service ;  namely,  plays  the 
role  of  anaesthetist,  assumes  the  care  of  the  patient,  and, 
in  addition  to  these,  performs  the  operation.  In  other 
words,  he  assumes  the  duties  of  anaesthetist,  nurse  and 
surgeon.  No  surgeon  would  undertake  to  administer 
his  own  anassthetic,  care  for  the  patient  and  perform 
an  operation,  except  in  the  extremest  emergency;  yet 
the  dentist  assumes  such  a  responsibility,  and  when 
failures  result  blames  nitrous  oxid,  never  for  a  moment 


General  Anccsiheiics  in  Deniistry.  117 

taking  into  consideration  that  he  has  attempted  to  ac- 
complish too  much. 

It  would  be  a  simple  matter  to  administer  ether  and 
extract  a  number  of  teeth  without  an  assistant,  as  com- 
pared to  administering  nitrous  oxid  alone  and  extract- 
ing a  number  of  teeth.  With  ether  you  could  anaesthe- 
tize the  patient  sufficiently  deep  to  complete  the  opera- 
tion before  beginning  to  operate ;  while,  with  pure  ni- 
trous oxid,  you  have  only  about  ninety  seconds  in 
which  to  ancesthetize  and  operate,  and  there  is  too  much 
for  any  one  man  to  do  in  so  brief  a  time. 

Nitrous  oxid  in  itself  is  an  excellent  anaesthetic; 
it  can  do  all  that  has  been  claimed  for  it,  and  those  who 
have  failed  to  successfully  administer  this  anaesthetic 
are  at  fault,  and  not  the  anaesthetic.  This  is  why  in  a 
previous  lecture  I  laid  so  much  stress  on  the  import- 
ance of  a  well-trained  assistant.  Indeed,  some  of  our 
most  successful  extracting  specialists  extract  only,  the 
assistant  assuming  the  entire  anaesthetic  responsibility. 
Let  us  assume,  then,  in  all  that  I  shall  say  in  regard  to 
administering  nitrous  oxid  gas,  whether  in  the  pure 
state  or  in  combination  with  admixtures  of  air  or  oxy- 
gen, that  a  good  assistant  is  as  essential  to  success  as 
an  appropriate  appliance,  as  a  good  anaesthetist  or  as  a 
skilful  extractor. 

If  you  have  not  read  the  lecture  on  "Elements  of 
Success,"  in  regard  to  the  proper  preparation  of  the 
patient,  both  mentally  and  physically,  preliminary  to 
administering  an  anaesthetic,  I  recommend  that  you  do 
so  before  perusing  this  lecture. 

The  patient  having  been  made  ready,  as  previously 


118  General  Ancesfhetics  in  Dentistry. 

explained,  with  a  g-ood  assistant  on  the  left  of  the  chair, 
the  patient  properly  and  comfortably  arranged  in  the 
chair,  only  the  mouth-prop  is  lacking;  that  adjusted, 
we  are  ready  to  consider  the  administration  of  nitrous  • 
oxid. 

Never  administer  nitrous  oxid  without  first  insert- 
ing a  mouth-prop.  Insert  the  mouth-prop  the  last  thing 
before  placing  the  inhaler  over  the  nose  and  face.  It 
is  never  safe  to  administer  nitrous  oxid  without  a 
mouth-prop,  and  I  consider  one  criminally  negligent 
to  do  so.  There  are  a  number  of  reasons  why  a  mouth- 
prop  should  be  used;  the  one  we  are  interested  in  just 
now  is  to  hold  the  jaws  apart  in  order  to  facilitate 
speedy  operating.  Many  dental  surgeons  fail  just  here. 
Under  nitrous  oxid  anaesthesia,  the  masticatory  muscles 
usually  contract,  sometimes  violently.  Having  satis- 
fied yourself  upon  removing  the  inhaler  that  the  patient 
is  sufficiently  anaesthetized  to  begin  operating,  if  a  prop 
has  not  been  used,  the  mouth  will  be  found  closed,  and 
sometimes  the  teeth  forcibly  held  together,  and  so  much 
time  is  consumed  in  opening  the  mouth,  if  it  can  be 
opened  at  all,  that  the  tooth  is  fractured  in  the  hurry,  or 
the  wrong  tooth  extracted,  or  the  patient  is  hurt,  or 
awakes  and  nothing  has  been  accomplished. 

Hewitt  gives  the  average  induction  period  of  nitrous 
oxid  gas  without  air  as  fifty-six  seconds,  and  the  aver- 
age available  anaesthesia  about  thirty  seconds,  so  there 
is  no  time  for  forcing  the  mouth  open,  and  it  is  highly 
important  that  the  mouth-prop  be  not  neglected. 

Let  rne  say  just  here,  make  it  a  rule  never  to  hurt 
your  patient.     Tlieir  object  in  taking  nitrous  oxid  gas 


General  AncBsthetics  in  Dentistry.  119 

is  to  avoid  the  pain  of  the  operation.  If  you  lose  too 
much  time  in  getting  started,  you  better  -not  operate 
at  all  than  to  have  the  patient  hurt.  The  patient  will 
complain  to  all  his  neighbors  that  he  knew  everything 
that  was  done,  and  was  never  so  badly  hurt  in  his  life, 
and  advise  everybody  he  meets  for  weeks  against 
taking  gas.  Exercise  the  greatest  of  care,  in  the  begin- 
ning, in  the  selection  of  suitable  subjects.  The  opera- 
tion itself  should  be  of  the  simplest  nature.  Some  one 
may  present  with  one  easy  tooth  to  extract,  or  two  or 
three  loose  pyorrhoea  teeth.  With  such  a  case,  there 
is  no  anxiety  about  the  operation,  but  your  entire  atten- 
tion can  be  given  to  administering  the  anjesthetic, 
studying  the  patient  and  learning  anesthetic  symptoms. 
It  is  unreasonable  on  your  part  to  expect  to  obtain  per- 
fect results  from  the  very  first  administration,  and  to 
start  in  as  an  accomplished  anaesthetist.  You  do  not 
expect  to  do  this  in  other  departments  of  dentistry 
when  you  take  up  something  new  that  you  are  not 
familiar  with. 

It  is  an  excellent  plan-  to  reserve  the  anaesthetic  for 
such  cases  forty,  fifty,  sixtv  times  or  more,  gaining 
confidence  each  time,  and  later  undertake  more  difficult 
cases.  If  a  patient  presents  "with  a  mouthful  of  teeth" 
to  be  extracted,  make  no  promise  in  advance  as  to  the 
number  you  will  remove  under  one  administration  of 
nitrous  oxid  gas.  If  you  should  promise  ten  and  suc- 
ceed in  extracting  but  three,  you  make  a  sad  failure. 
Say  this:  'T  will  extract  as  many  as  I  possibly  can,  and 
will  not  hurt  you,''  and  be  sure  to  cease  extracting  be- 
fore  they   feel   pain.     You    might   say  that  "nuich   de- 


120  General  Ancesthetics  in  Dentistry. 

pends  upon  the  breathing"."  as  explained,  and  that 
"some  patients  are  more  deeply  anesthetized  than 
others."  If  you  succeed  in  removing  three  or  four 
teeth,  3'ou  are  safe;  if  you  should  succeed  in  extracting 
eight  or  ten  teeth,  your  reputation  is  made  with  that 
patient.  Whatever  the  number,  be  sure  to  stop  before 
the  patient  feels  pain.  Better  not  extract  at  all  if  from 
nervousness  the  patient  does  not  take  the  anaesthetic 
well;  but  have  him  return  another  day.  It  will  con- 
demn any  anaesthetic  to  operate  too  soon  or  too  long 
and  the  patient  to  feel  the  pain. 

In  regard  to  extracting  under  nitrous  oxid,  let  me 
say  it  is  a  very  different  proposition  from  extracting 
without  an  anaesthetic.  It  is  something  that  has  to  be 
learned,  no  matter  how  skilful  an  extractor  you  may  be. 
Without  an  ansesthetic,  the  patient  keeps  his  tongue  out 
of  the  way,  and,  in  a  degree,  the  cheeks,  and  the  mouth 
opens  wider  if  you  wish  it,  and  the  head  turns  to  one 
side  or  the  other;  but,  under  nitrous  oxid  gas,  you  must 
be  careful  not  to  wound  the  tongue  or  cheeks,  must  ac- 
commodate yourself  to  thC;;  space  obtained  by  the 
mouth-prop,  and  operate  speedily. 

To  return  again  to  the  administration  of  nitrous 
oxid  gas,  measures  must  be  taken  to  exclude  all  air. 
Adjust  the  inhaler  to  the  face  and  satisfy  yourself  that 
it  fits  accurately.  The  pneumatic  cushion  or  rim  should 
not  be  blown  up  too  tightly,  but  about  half  full  of  air ; 
then  it  can  more  accurately  be  made  to  conform  to  the 
features  than  when  more  tense  or  rigid.  If  the  patient 
wears  a  heavy  mustache  or  beard,  especially  the  beard, 
it  is  an  excellent  plan  to  dampen  some  surgeon's  gauze 


General  Anaesthetics  in  Dentistry.  121 

and  place  thr^e  or  four  layers  around  the  rim,  then 
press  this  tightly  against  the  beard  with  the  inhaler. 
Have  the  assistant  release  the  gas  and  allow  it  to  pass 
into  the  rubber  bag  until  it  is  almost  full.  Shut  off  the 
gas  for  a  moment,  open  the  exit  valve  and  the  gas  in  the 
bag  will  force  out  of  the  tube  running  from  the  bag  to 
the  inhaler  the  air  it  contains.  It  is  very  important 
that  the  valves  should  work  accurately  and  sensitively. 
Adjust  the  face-piece  carefully  this  time  and  see  that 
no  air  can  gain,  admittance  under  the  pneumatic  rim, 
the  valves  having  been  tested  previously  to  ascertain 
if  they  are  in  perfect  working  order.  Instruct  the  pa- 
tient to  breathe  deeply  and  regularly.  I  prefer  in  the 
beginning  that  they  take  three  or  four  inhalations  of 
air  through  the  inhaler,  the  gas  being  shut  off;  then 
gradually  admit  the  nitrous  oxid  gas.  From  this  time 
on,  exclude  all  air.  The  assistant  should  now  keep  the 
gas  bag  about  two-thirds  full,  and,  when  the  patient  is 
sufficiently  anaesthetized,  be  sure  to  turn  the  gas  off 
tightly  at  the  cylinder. 

Judging  from  my  own  experience,  eight  gallons  is 
the  average  amount  of  nitrous  oxid  gas  necessary  to  in- 
duce anaesthesia,  when  all  air  is  excluded ;  Hewitt  says 
six.  In  some  cases,  I  have  found  two  or  three  gallons 
sufficient;  in  others,  fifteen  or  twenty  gallons.  Frail 
patients,  children  and  ancemics  are  very  susceptible  to 
nitrous  oxid  gas ;  the  plethoric  and  alcoholics  require 
a  greater  amount.  The  condition  of  the  patient,  of 
course,  is  the  test  in  all  cases  ;  nevertheless  it  was  very 
satisfying  under  the  gasometer  plan  when  it  was  pos- 


122  General  Ancesthetics  in  Dentistry. 

sible  to  see  the  indicator  and  note  the  number  of  gallons 
that  were  being  inhaled. 

The  induction  period  of  nitrous  oxid  gas  is  so  brief 
and  the  phenomena  occur  in  such  rapidity,  that  I  have 
not  been  able  to  make  a  satisfactory  classification  of 
symptoms.  The  four  anaesthetic  stages  are  easily  dis- 
cernible under  alcohol,  ether  and  chloroform  ;  but  the 
action  is  so  quick  under  pure  nitrous  oxid  gas,  ethyl 
chloride  and  somnoform,  that  I  have  not  been  able  to 
differentiate  them.  Hewitt  has  more  thoroughly  inves- 
tigated and  experimented  with  nitrous  oxid  gas  than 
any  other  writer,  and  he  also  speaks  of  the  difficulty  of 
classifying  nitrous  oxid  gas  phenomena  into  four 
groups;  yet  his  intimate  knowledge  of  the  subject  has 
enabled  him  to  accomplish  this,  and  we  will  follow  his 
outline. 

First  Stage.  Patients  vary  greatly  in  the  matter  of 
symptoms  experienced  during  the  inhalation  of  nitrous 
oxid  gas.  This  is  to  be  expected,  because  an 
ancesthetic  does  not  destroy  one's  personality.  No 
two  patients  probably  have  an  identical  experience. 
This  is  true  in  the  more  common  things  of  life.  I  have 
been  frequently  annoyed  at  the  theater  by  those  about 
me  laughing  audibly  when  to  me  the  grouping  was  pa- 
thetic, and  at  other  times  situations  that  appealed  to  me 
as  humorous,  brought  no  smile  to  the  countenance  of 
my  neighbors.  If  3'ou  had  an  opportunity  to  treat  five 
men  to  a  large  drink  of  whisky,  just  as  they  happened  to 
be  in  a  group,  and  kept  them  together  long  enough  to 
study  the  effect,  they  would  not  react  alike  to  this  stim- 


General  Anceslhetics  in  Dentistry.  123 

ulant.  One  man  would  probably  become  talkative,  an- 
other feel  like  singing,  another  become  drowsy,  another 
no  effect  at  all,  according  to  their  individual  tempera- 
ment. Even  in  the  condition  w^e  call  sleep,  which  is 
purely  physiological,  individuals  vary  widely.  Some 
sleep  lightly  and  are  easily  disturbed,  while  others  sleep 
profoundly  and  nothing  disturbs  them..  Some  experi- 
ence the  wildest  kind  of  dreams,  horrible  to  relate ;  oth- 
ers in  their  dreams  have  visions  sublime.  Just  as  the 
harrowing  incidents  of  the  day  disturbs  the  mind  to  the 
degree  of  sleeplessness,  so  in  a  disturbed  mental  state 
patients  do  not  sleep  quietly  and  tranquilly  under  an 
anaesthetic.  This  condition  and  how  to  overcome  it  is 
discussed  in  the  lecture  on  "Elements  of  Success." 

When  nitrous  oxid  is  administered  properly,  the  pa- 
tient having  been  made  ready  mentally  and  physically, 
the  sensations  experienced  are  more  likely  to  be  oi  an 
agreeable  than  of  a  disagreeable  character.  This  is 
characteristic  of  nitrous  oxid  when  inhaled  experiment- 
ally, and,  if  it  is  not  so  when  an  operation  is  to  be  per- 
formed, it  shows  that  the  disturbed  mentality  incident 
to  the  operation  is  the  disturbing  element  rather  than 
the  nitrous  oxid  gas. 

Should  the  apparatus  possess  valves  which  do  not 
work  easily,  or  should  the  channels  through  which  the 
gas  is  made  to  pass  be  too  small,  or  should  the  patient 
through  the  want  of  confidence  or  knowledge  breathe 
in  a  shallow  or  restricted  manner,  or  through  the  nose, 
an  unpleasant  experience  may  result.  Hewitt  insists 
on  mouth  breathing  when  pure  nitrous  oxid  gas  is  be- 


124  General  AncBsthetics  in  Dentistry. 

ing  administered.  I  never  instruct  patients  in  regard  to 
this  point,  lest  they  become  confused,  but  in  the  deep 
breathing  required,  when  the  mouth  is  held  open  by  a 
prop,  I  think  there  is  a  combination  of  both  nasal  and 
mouth  inhalation  and  that  the  latter  predominates.  An 
"indescribable  pleasant  numbness  all  over  the  body 
and  a  feeling  of  warmth  in  the  lips"  are  amongst  the 
first  sensations  experienced.  Following  these  is  a 
peculiar  pleasurable  "thrilling"  which  hardly  admits  of 
description.  Then  follows,  with  some,  a  ringing  in  the 
ears,  tinnitus,  and  a  fulness  in  the  head,  caused  by  in- 
creased circulation  of  the  blood.  It  is  at  this  stage  that 
those  who  are  affected  unpleasantly  begin  to  hear  and 
see  things,  and  the  quicker  over,  the  better.  The  loss 
of  consciousness  comes  on  now  before  the  patient  has 
time  to  define  his  feelings.  The  pulse  grows  fuller 
under  the  finger;  and  its  caliber  is  somewhat  increased 
at  this  stage.  The  power  of  hearing  still  persists  and 
noises  or  conversation  has  a  tendency  to  excite  the  pa- 
tient. In  my  early  anaesthetic  practice  I  used  a  small 
music  box  and  it  was  just  at  this  stage  that  the  assist- 
ant was  signalled  to  touch  it  off.  The  average  time  of 
this  first  stage,  from  the  commencement  of  the  inhala- 
tion of  nitrous  oxid  gas  till  the  loss  of  consciousness, 
is  about  thirty  seconds. 

Second  Stage.  With  the  loss  of  normal  conscious- 
ness disturbed  psychical  states  arise.  As  a  rule,  the 
patient  gives  little  or  no  evidence  of  such  disturbance, 
more  especially  if  allowed  to  remain  perfectly  quiet. 
If  roughly  handled,  the  patient  is  liable  to  become  ex- 


General  Ancesthetics  in  Dentistry.  125 

cited  and  move  his  hands  and  legs.  Any  injury  inflicted 
during  this  stage  may  produce  immediate  reflex  effects, 
such  as  shouting,  co-ordinate  or  inco-ordinate  move- 
ments, but  it  would  not  be  accurately  remembered  by 
the  patient.  This  stage  is  often  mistaken  by  dental 
surgeons  for  the  anaesthetic  stage  and  they  begin  to 
operate,  and  sometimes  have  disastrous  results.  The 
patient  yells,  screams,  struggles,  and  if  strong  enough 
breaks  away;  frees  himself  if  possible,  and  there  are 
instances  on  record  where  the  anaesthetist  has  suffered 
physical  violence.  Other  operators  at  this  stage,  if  the 
patient  becomes  a  little  nervous — attempts  to  move  or 
struggle — imagine  that  this  is  one  of  the  cases  in  which 
the  patient  does  not  take  nitrous  oxid  well,  "he  is 
probably  as  deep  as  I  can  get  him,  I  had  better  extract 
quickly,"  and  he  does  and  is  apt  to  have  a  fight  on  his 
hands.  A  few  more  inhalations  just  at  this  time  would 
have  induced  surgical  anaesthesia. 

Nitrous  oxid  is  often  accused  of  producing  imper- 
fect anaesthesia,  because  operations  are  sometimes  com- 
menced at  this  stage.  Many  nitrous  oxid  gas  appli- 
ances have  been  relegated  to  the  garret  or  laboratory  on 
account  of  the  chagrin  felt  by  the  dentist  after  an  expe- 
rience of  this  kind  when  neither  the  appliance  or  the 
anaesthetic  was  at  fault,  the  operator  simply  mistaking 
the  second  stage  for  the  surgical  stage. 

Dreams  are  common,  but  are  rarely  distinctly  re- 
membered. These  depend  largely  on  the  mental  state 
of  the  patient  at  the  time  of  losing  consciousness,  and 
sometimes  on  the  kind  of  dreams  experienced  during 


126  General  Ancesthetics  in  Dentistry. 

natural  sleep.  I  recall  a  patient  who  had  apparently  a 
horrible  dream.  She  made  the  most  hideous  of  noises, 
and  seemed  to  be  suffering  the  torments  of  the  damned. 
After  she  returned  to  consciousness,  the  friend  who  ac- 
companied her  told  me  the  patient  frequently  had  just 
such  "nightmares"  in  her  sleep  at  home.  Fortunately 
the  dreams  that  occur  under  nitrous  oxid  gas  anaesthe- 
sia are  usually  of  a  pleasing  rather  than  of  a  disagree- 
able nature.  Hewitt  maintains  that  it  is  a  curious  fact 
that  unpleasant  dreams  are  more  common  under  nitrous 
oxid  gas  per  se  than  under  nitrous  oxid  gas  and  oxy- 
gen, probably  because  the  anaesthesia  in  the  latter  case 
is  deeper,  so  that  operations  or  other  interferences, 
which  in  the  case  of  nitrous  oxid  gas  itself  might  leave 
some  disturbed  impressions,  are  not  capable  of  doing 
so  when  the  anaesthesia  is  more  profound. 

In  this  stage  respiration  is  still  quicker  and 
deeper  than  normal,  and,  save  perhaps  for  an  occa- 
sional swallowing,  is  perfectly  regular.  The  pulse 
is  still  full  and  a  trifle  quicker  than  in  the  first 
stage.  In  some  cases,  a  spurious  form  of  stupor 
may  occur  and  it  is  to  be  disregarded.  The  con- 
junctiva is  sensitive  to  touch.  The  pupils  usually 
grow  larger  as  the  administration  proceeds.  The  eye- 
lids are  usually  affected  by  a  slight  twitching;  and,  as 
the  inhalation  proceeds,  they  have  a  tendency  to  sep- 
arate and  to  display  the  subjacent  globes.  As  the  lids 
separate  and  the  eyeballs  become  more  prominent  and 
fixed,  the  features  lose  their  normal  color,  and  become 
dusky,  then  livid.     Blonds  are  more  susceptible  to  dus- 


General  Ancesthetics  in  Dentistry.  127 

kiness  and  lividity  of  features  than  brunettes.  Sallow 
people  show  very  little  change  of  color.  At  the  close 
of  this  second  stage,  the  respiration  is  deeper  and  fuller 
and  the  pulse  stronger  than  at  any  previous  time  and 
the  patient  is  in  the  best  possible  condition. 


128  General  Ancesthetics  in  Dentistry. 


LECTURE  XI. 

Nitrous    Oxid   Gas   Administration — Continued. 

Third  Stage.  The  first  indication  that  the  patient  is 
passing-  or  has  passed  into  the  third  stage  of  anaesthesia 
is  usually  afforded  by  the  respiration.  The  breathing", 
which  hitherto  preserved  its  rhythm,  now  loses  it,  and 
a  peculiar  characteristic  throat  sound,  sometimes  de- 
scribed as  "stertor,"  becomes  audible.  This  sound  is 
most  probably  due  to  irregular  spasmodic  elevations  of 
the  larynx  towards  the  epiglottis  and  base  of  the 
tongue,  and  indicates  the  tendency  to  obstruction  in  the 
air-way  at  this  point.  It  occasionally  happens  that  th6 
respiration  becomes  somewhat  feeble ;  or  expiration  be- 
comes somewhat  prolonged  and  rather  strained.  These 
phenomena  should,  in  the  presence  of  other  signs  of 
anassthesia,  be  taken  to  mean  that  the  administration 
has  been  pushed  far  enough.  Now  is  the  proper  time 
to  begin  to  operate.  To  wait  longer  is  to  invite  danger. 
The  heart  is  still  beating  strong,  and  the  pulse  is  very 
full  and  rapid.  As  to  how  much  of  an  operation  may  be 
attempted  depends  largely  upon  the  operator  and  also 
upon  the  patient.  You  can  learn  this  only  by  experi- 
ence. Some  operators  are  more  expert  than  others, 
some  are  quicker  than  others  and  have  more  confidence 
in  themselves.     Some  dental  surgeons  seem   to  know 


General  Aruesthetics  in  Dentistry.  129 

by  intuition  when  to  cease  operating;  others  never 
seem  to  know  the  limitations  of  pure  nitrous  oxid  gas 
anaesthesia.  Some  patients  are  more  profoundly  anaes- 
thetized by  the  inhalation  of,  say,  eight  gallons  of 
nitrous  gas  than  others,  and  the  period  of  operating  will 
be  two  or  three  times  as  long.  With  some  patients, 
there  is  hardly  enough  ^time  to  make  one  difficult  ex- 
traction, while  others  as  many  as  eighteen  or  twenty 
teeth  may  be  removed.  Remember  that  the  average 
available  anesthesia  inducted  by  pure  nitrous  oxid  gas 
is  only  thirty  seconds. 

A  pulse  that  was  one  hundred  and  twenty  immedi- 
ately before  the  administration  may,  for  example,  rise 
to  one  hundred  and  sixty  or  more ;  whereas  a  pulse  of 
eighty  or  ninety  at  the  beginning  of  the  inhalation  will 
not  exceed  one  hundred  or  one  hundred  and  ten  in  the 
third  stage.  Immediately  that  air  is  admitted  by  the 
withdrawal  of  the  anaesthetic,  the  pulse  abruptly  un- 
dergoes a  marked  change.  It  at  once  becomes  slower 
and  fuller.  A  pulse  at  one  hundred  and  forty  at  the 
acme  of  anaesthesia  may  suddenly  drop  to  about  eighty 
per  minute  before  the  effects  of  the  anaesthesia  have 
passed  oft*. 

Various  muscular  phenomena  may  appear.  When 
respiration  undergoes  the  changes  referred  to,  the  arm, 
if  raised,  will  generally  fall.  But  there  is  a  tendency  for 
clonic  muscular  contractions  to  occur  in  all  cases,  and 
for  tonic  spasm  to  arise  in  many.  In  some  cases,  the 
facial  muscles  are  chiefly  aft'ected  by  the  convulsive 
seizure ;  in  others,  the  whole  body  mildly  oscillates,  the 
spasm  apparently  chiefly  aft"ecting  the  trunk  muscles; 


130  General  Anaesthetics  in  Dentistry. 

in  others,  the  hands,  legs,  and  arms  alone  may  twitch ; 
whilst,  in  a  fourth  group  of  cases,  the  neck  may  be 
affected  by  barely  perceptible  clonic  spasm,  so  that  the 
head  is  felt  to  move  with  fine  rhythmic  jerks  in  one  or 
other  directions. 

Dr.  Buxton  found  that  one-third  of  the  men  and 
nearly  one-third  of  the  women  angesthetized  by  him 
at  the  Dental  Hospital  displayed  ankleclonus  under 
nitrous  oxid. 

^Micturition  rarely  occurs,  but  it  is  sometimes  met 
with  in  children.     Defecation  is  extremely  uncommon. 

The  pupils  in  a  majority  of  the  cases  are  dilated 
in  deep  nitrous  oxid  gas  anaesthesia.  In  some  cases, 
however,  they  remain  a  moderate  size  or  may  be  con- 
tracted. The  conjunctival  reflex,  which  will  have  per- 
sisted during  most  of  the  administration,  becomes  less 
marked  or  disappears.  It  can  not  be  depended  upon  as 
a  guide.    The  corneal  reflex  usually  persists. 

Fourth  Stage.  If  all  air  has  been  excluded  and  the 
patient  is  still  inhaling  pure  nitrous  oxid  gas,  there  is 
danger  now  of  an  overdose,  which  constitutes  the 
fourth  stage  of  anaesthesia.  Hewitt  has  said  that  dan- 
gerous asphyxia  will  occur  in  fifty-six  seconds  (average 
time)  if  all  air  is  excluded,  and  he  also  states  that  the 
average  time  required  to  induce  surgical  anaesthesia  is 
fifty-six  seconds.  There  is  then  no  working  margin, 
and  the  anaesthetist  should  be  extremely  careful  at  this 
stage  of  induction.  As  careful  as  we  may  be,  however, 
to  exclude  air,  it  is  probable  that  some  air  has  been 
admitted   to  tlie   lungs.     Always  be   guided  by  anaes- 


General  Ancesthetics  in  Dentistry.  131 

thetic  symptoms — no  one  should  think  of  guaging  the 
time  at  which  to  operate  merely  by  the  watch. 

If  an  overdose  of  nitrous  oxid  gas  is  administered, 
the  breathing-  becomes  embarrassed  and  then  ceases, 
either,  as  Hewitt  says,  as  the  result  of  muscular  spasm 
or  by  the  more  commonly  accepted  cause,  paralysis  of 
the  respiration.  The  more  vigorous  the  patient,  the 
more  powerful  will  be  the  spasm.  At  the  time  the 
breathing  ceases,  the  color  of  the  face  is  a  deep  purple, 
sometimes  even  black,  pupils  usually  dilated,  the  eyelids 
widely  separated,  and  the  cornea  prominent  and  fixed. 
In  strong  and  vigorous  patients,  the  heart  sometimes 
continues  for  a  period  of  several  minutes,  and,  at  the 
time  that  respiration  ceases,  it  is  not  always  depressed. 
On  the  other  hand,  in  debilitated  patients  with  weak  or 
fatty  hearts,  delayed  respiration  will  more  speedih^  be 
followed  by  cardiac  arrest.  There  seems  to  be  no  case 
on  record  in  which  death  has  resulted  from  primary 
circulatory  arrest,  following  the  administration  of 
nitrous  oxid  gas. 

As  pointed  out  in  previous  lectures,  it  is  all  import- 
ant to  observe  the  respiration,  for  as  long  as  the  respira- 
tion is  properly  performed,  the  heart  will  take  care  of 
itself.  It  behooves  the  dental  anaesthetist  to  know  res- 
piration thoroughly,  and  he  should  familiarize  himself 
with  the  anatomy  of  the  respiratory  tract,  especially 
the  nerves  that  supply  and  control  the  respiratory 
muscles. 

Swollen  and  enlarged  tongue  is  common  to  pure 
nitrous  oxid  gas  anzesthesia.  This  condition  is  depend- 
ent upon  the  engorgement  of  the  blood  vessels  of  the 


132  General  An<Bsthetics  in  Dentistry. 

tongue.  If  the  tongue  becomes  thus  engorged,  it  is 
probable  that  the  blood  vessels  along  the  entire  respira- 
tory tract  are  also  congested.  It  becomes  important  to 
satisfy  ourselves  whether  the  patient  has  nasal  sten- 
osis, pharyngeal  adenoids,  enlarged  tonsils,  oedema  of 
the  uvula,  morbid  growths  of  the  soft  palate,  larynx  or 
trachea,  or  any  other  condition  that  may  impede  or 
make  more  labored  the  respiration.  When  patients  do 
not  take  nitrous  oxid  gas  well  and  become  unduly  ex- 
cited or  cyonotic  too  soon,  the  condition  probably  arises 
from  some  respiratory  obstruction,  rather  than  from 
nitrous  oxid  gas,  per  se. 

Hewitt  made  a  careful  search  of  the  dental  and 
medical  journals  for  records  of  nitrous  oxid  gas  deaths 
from  1860-1900,  and  found  but  thirty  recorded.  He  has 
placed  these  in  appropriate  groups  and  they  make  a 
most  interesting  and  profitable  studv.  Class  A  he  des- 
ignates deaths  undoubtedly  due,  partly  or  wholly,  to 
nitrous  oxid  gas. 

Case  1.  Female,  Z'&;  stout;  enlarged  tonsils  and 
uvula ;  dental  operation ;  double  administration ;  as- 
phyxia. ^        ' 

Case  2.  Male,  middle-aged;  obese;  dental  opera- 
tion ;  double  administration ;  asphyxia. 

Case  3.  Male,  57;  tongue  enlarged  by  morbid 
growth  and  fixed ;  dental  operation ;  convulsive  tremor 
and  rigidity;  asphyxial  syncope. 

Case  4.     Male,  about  50 ;  dental  operation  ;  syncope. 

Case  5.  Female,  71 ;  stout ;  corsets  tight ;  food  in 
stomach ;  dental  operation ;  probably  asphyxia. 

Case  6.     Male,  24;  dental  operation,  syncope. 


General  Ancesthetics  in  Dentistry.  133 

Case  7.  Female,  dental  operation ;  mode  of  death 
uncertain. 

Case  8.  Male,  39;  small  and  deformed  lower  jaw; 
dental  operation ;  asphyxia. 

Case  9.  Female,  dental  operation ;  asphyxia  prob- 
ably favored  by  morbid  state  of  upper  air-passages. 

Case  10.  Male,  26;  enlarged  tonsils;  receding  low- 
er jaw ;  short  neck ;  dental  operation ;  asphyxia. 

Case  11.  Female,  23;  tight  corsets;  full  stomach; 
dental  operation ;  asphyxia. 

Case  12.     Female,  22;  dental  operation. 

Case  13.     Male ;  dental  operation ;  asphyxia. 

Case  14.  Male,  12 ;  large  abscess  in  base  of  tongue; 
fixed  lower  jaw ;  opening  abscess ;  asphyxia. 

Case  15.  Male,  7;  very  delicate;  old  standing  peri- 
carditis and  pleurisy;  dorsal  posture;  operation  for 
adenoids;  nitrous  oxid  given  with  air;  syncope;  no  ob- 
struction in  breathing. 

Case  16.  Female,  27 ;  food  in  stomach  ;  double  ad- 
ministration ;  vomiting ;  dusky  pallora ;  syncope ;  opera- 
tion on  elbow. 

Case  17.  Male,  36;  suppuration  of  neck;  left  tonsil 
swollen ;  incision  of  neck ;  nitrous  oxid  with  air  first 
given ;  then  pure  nitrous  oxid ;  cessation  of  respiration ; 
death  from  asphyxia ;  at  necropsy,  larynx  found  to  be 
odematous. 

In  13  deaths  out  of  a  total  of  17  deaths,  the  opera- 
tion was  classified  as  dental.  And  it  would  seem  that 
in  nearly  all  of  these  deaths  some  pre-existing  condi- 
tions were  present  to  which  these  deaths  might  be  at- 
tributed.   In  Case  1,  enlarged  tonsils  and  uvula  and  a 


134  General  Anaesthetics  in  Dentistry. 

double  administration.  Case  2,  patient  "obese"  and 
double  administration.  Case  3,  tongue  enlarged  by 
morbid  growth.  Case  5,  corsets  tight  and  food  in 
stomach.  Case  7,  double  administration.  Case  8, 
small  and  deformed  lower  jaw.  Case  10,  enlarged 
tonsils.     Case  11,  tight  corsets  and  full  stomach. 

Out  of  the  thirteen  dental  cases,  there  were  three 
double  administrations,  two  with  tight  corsets,  and  two 
with  full  stomachs. 

Nitrous  oxid  anesthesia  is  so  quickly  induced  and  is 
of  such  brief  duration  that  unpleasant  after-effects  are 
generally  avoided.  Once  in  a  while,  a  patient  with  a 
very  delicate  stomach,  one  that  is  subject  to  car  sick- 
ness or  that  strong  odors  of  any  kind  affect  unpleasant- 
ly, may  become  nauseated.  Weakness  and  exhaustion 
rarely  follow.  Plethoric  or  full-blooded  people,  if  they 
are  subject  to  attacks  of  headache,  may  suffer  a  few 
hours  from  cephalgia.  Patients  more  frequently  leave 
the  office,  stimulated  and  bouyant  than  depressed  and 
morose. 

Nitrous  oxid,  in  my  estimation,  is  not  an  ideal  ilen- 
tal  anaesthetic.  It  is  entirely  too  brief  in  its  action  to 
be  universally  successful.  As  patients  come  to  mc  to 
be  anaesthetized  from  other  operators,  more  condemn 
nitrous  oxid  than  praise  it.  Occasionally  some  one 
will  say,  "My  experience  with  nitrous  oxid  was  pleas- 
ant, the  operation  a  success,  and  I  would  even  go  to 
Chicago  rather  than  have  a  tooth  extracted  without  it." 
For  every  expression  of  this  kind  I  hear  ten  who  de- 
clare with  them  nitrous  oxid  was  a  failure.  Not  only 
was  the  pain  inflicted  severe,  but  it  was  accompanied 


General  Ancjesthetics  in  Deyitisiry.  135 

with  a  hideous  nightmare.  Those  dental  surgeons 
who  are  successful  in  administering  nitrous  oxid  will 
think  that  I  have  overstated  the  case,  but  the  hundreds 
of  dentists  who  have  discarded  their  gasometers  and 
have,  some  of  them,  two  or  three  kinds  of  nitrous  oxid 
appliances  hid  away  in  closets  and  laboratories  will 
say  that  I  have  underestimated  rather  than  overdrawn 
the  situation. 

Thirty  seconds  of  available  ant"esthesia  is  not  suffi- 
cient for  dental  purposes.  It  is  entirely  too  brief  for 
the  average  dental  surgeon  and  it  is  the  average  den- 
tist that  must  be  satisfied.  Even  our  most  skilled  den- 
tal anaesthetists  and  our  most  expert  extracting  special- 
ists are  many  times  defeated  in  accomplishing  a  cer- 
tain operation  on  account  of  the  brevity  of  pure  nitrous 
oxid  anaesthesia. 

Its  greatest  advantage  is  its  safety.  It  is  safe  only 
because  the  patient's  behavior  and  appearance  are  such 
that  the  dental  surgeon  has  not  the  courage  to  push 
the  anaesthetic  even  to  the  proper  stage  for  operating, 
and  makes  a  sad  failure.  The  bulging  eyeballs,  the 
dusky  complexion,  the  stertorous  breathing-,  the  con- 
tortion of  the  face  muscles  and  the  distressed  appear- 
ance of  the  patient  frightens  the  dentist  into  operating 
too  soon,  but  no  doubt  saves  the  life  of  the  patient  in 
many  cases. 

Hewitt  has  said  it  is  a  dangerous  procedure  to  ex- 
clude air  for  more  than  fifty-feix  seconds  when  pure 
nitrous  oxid  is  being  inhaled,  and  he  also  says  that  the 
average  time  required  to  induce  surgical  anaesthesia 
with   nitrous   oxid.   with    all    air   excluded,   in   fiftv-six 


136  General  Ancesthetics  in  Dentistry. 

seconds,  so  it  is  evident  that  according  to  the  acknowl- 
edged nitrous  oxid  authority,  the  point  of  surgical  anaes- 
thesia and  the  danger  point  are  the  same. 

The  dental  surgeon  in  nearly  all  cases  makes  a 
failure  of  nitrous  oxid ;  the  extracting  specialist  through 
long  training  and  frequent  daily  use  knows  the  possi- 
bilities and  limitations  of  pure  nitrous  oxid.  But  there 
is  only  about  one  extracting  specialist  to  each  thousand 
dentists. 

Pure  nitrous  oxid  as  an  anaesthetic  has  had  its  day. 
Only  in  the  most  simple  cases  of  extracting  should  it 
be  used,  if  at  all.  Indeed,  there  is  no  longer  a  necessity 
for  employing  this  anaesthetic  agent. 

It  has  been  demonstrated  that  by  adding  definite 
proportions  of  oxygen  to  nitrous  oxid,  instead  of  an 
available  anaesthesia  of  thirty  seconds,  an  indefinite 
anaesthesia   can  be   maintained. 

Not  only  can  prolonged  anaethesia  be  maintained, 
but  a  safe  anaesthesia.  Anaesthesia  is  now  possible 
without  cyanoies,  without  jactitation,  without  ap- 
proaching the  danger  line,  for  no  death  has  ever  been 
reported  as  arising  from  nitrous  oxid  and  oxygen  anaes- 
thesia. 

Before  discussing  nitrous  oxid  and  oxygen,  which 
naturally  should  be  considered  now,  I  wish  to  call  your 
attention  to 

Nitrous  Oxid  Warmed. 
I  have  learned  that  nitrous  oxid  warm  is  superior 
to  nitrous  oxid  cold  as  an  anaesthetic.     The  appliance 
I  use  mostly  when  teeth  are  to  be  extracted  or  for  sur- 
gical  operations  has  a  thermometer  in   the  "mixing- 


General  Ancestheiics  in  Dentistry.  137 

chamber,"  and  I  know  the  temperature  when  nitrous 
oxid  leaves  that  chamber  if  not  when  it  enters  the  h:ngs. 
Although  I  knew  that  nitrous  oxid  as  it  passed  out  of 
the  rubber  bag-  was  cold,  I  did  not  realize  till  I  made 
the  test  for  myself  that  the  cold  was  so  intense  as  it 
passed  into  the  lungs.  For  an  ordinary  case  of  ex- 
tracting in  which  eight  or  nine  gallons  of  the  gas  is 
consumed  the  thermometer  falls  to  20°  F. — or  twelve 
degrees  below  the  freezing-point.  In  prolonged  cases 
I  have  seen  the  thermometer  settle  to  10°  F.  The  gas 
passes  first  into  the  rubber  bag,  then  into  the  "mixing- 
chamber,"  containing  the  thermometer,  and  from  there 
through  the  tubing  to  the  inhaler  and  the  nose.  How 
much  the  temperature  of  the  gas  is  raised  passing 
through  four  feet  of  tubing,  the  nares  and  pharynx, 
rapidly  inhaled,  I  do  not  know.  But  I  do  know  that 
the  mucous  membrane  over  which  the  gas  passes  so 
rapidly  becomes  chilled,  and  that  we  are  not  warranted 
in  turning  such  a  cold  draft  into  the  bronchi  and  lungs. 
In  a  conversation  recently  with  one  of  our  leading  phy- 
sicians I  was  advocating  the  use  of  nitrous  oxid  prelim- 
inary to  ether  and  chloroform.  He  remarked,,  "That  was 
my  custom  for  years,  but  it  was  productive  of  so  much 
bronchial  and  lung  trouble  on  account  of  the  irritating 
properties  of  the  gas  that  I  abandoned  its  use."  "\\''hy, 
man,"  I  said,  "nitrous  oxid  is  not  irritating."  He  in- 
sisted that  it  was.  Then  I  asked  him  if  he  knew  the 
temperature  of  nitrous  oxid  as  it  left  the  bag  to  enter 
the  lungs;  he  said  "no."  I  informed  him— a  blank  look 
came  over  his  face.  In  a  moment  he  said.  "It  was  the 
extreme  cold.  then,  that  caused  mv  cases  of  bronchitis 


138  General  Ancesihetics  in  Dentistry. 

and  pneumonia,  was  it  not?"  I  know  if  I  remove  my 
collar  and  the  mildest  kind  of  a  draft  strikes  the  back 
of  my  neck,  I  have  a  cold  and  a  stiff  neck  next  day,  If 
the  outside  of  the  neck  is  so  sensitive  to  thermal 
changes,  I  should  think  the  inside  would  become  in- 
volved if  I  breathed  deeply  and  rapidly  a  gas  which 
entered  my  nose  at  a  temperature  of  10°-20° — i>elow 
freezing-point. 

AVith  the  gas  warmed,  the  patient  passes  into  as 
quiet  and  as  beautiful  an  anaesthesia  as  we  obtain  with 
somnoform.  No  jactitation,  seldom  yelling,  screaming 
and  laughing  so  common  with  the  usual  method,  and  by 
admitting  a  small  quantity  of  oxygen,  no  discoloration 
or  asphyxia. 

I  have  administered  nitrous  oxid  cold,  twenty-three 
years  and  nitrous  oxid  warm  three  years,  and  I  have 
not  the  language  at  my  command  to  tell  you  how 
pleased  I  am  with  Avarm  nitrous  oxid.  A  cup  holding 
about  a  quart  of  water  fits  round  the  neck  of  the  cylin- 
der and  rubber  attached  to  the  cup  fits  tightly  about 
the  cylinder  as  rubber  dam  hugs  the  neck  of  the  tooth 
over  which  it  is  placed.  In  this  cup  I  pour  water  at 
a  temperature  of  130°  F.  The  valve  of  the  cylinder 
stands  in  this  cup,  so  there  is  no  freezing  of  the  valve 
and  a  small  coil  about  an  eighth  of  an  inch  in  diameter 
passes  from  the  valve  and  circumscribes  it  several 
times;  this  also  is  submerged  in  the  Avater.  Liberating 
the  gas  by  turning  the  wheel  and  allowing  it  to  pass 
through  the  coil  and  bag  into  the  mixihg-chamber 
containing  the  thermometer,  instead  of  20°  F.  the 
llicrmdiufler   registers    from    70°-75'^    F.   or   about   the 


General  Ancesfhetics  in  Dentistry.  139 

same  temperature  as  the  air  in  the  room  to  which  the 
lungs  are  accustomed.  If  the  anaesthesia  be  a  pro- 
longed one,  the  assistant  at  intervals  pours  a  little 
more  hot  water  from  a  pitcher,  and  the  temperature 
can  be  easily  maintained  (Brown  Aniestheti/'jer). 
The  Hurd-Richardson-Brom  Allen-Clark  combination 
gas  apparatus  is  admirably  adapted  for  the  use  of 
warm  nitrous  oxid.  This  appliance  has  a  mixing- 
chamber  containing  about  a  quart  of  water.  This 
water  is  used  for  a  different  purpose,  however.  By 
using  water  about  130°  F.,  it  will  serve  every  purpose 
tor  which  the  water  is  intended,  and  you  have, 
in  addition,  the  advantage  of  nitrous  oxid  heated  to 
the  temperature  of  the  atmosphere  of  the  room.  This 
appliance  is  well  adapted  for  operations  on  the  teeth 
other  than  extracting,  such  as  preparation  of  cavities, 
removing  pulps,  shaping  teeth  for  crowns,  etc.  The 
water  once  warmed  is  sufficient  for  these  cases,  be- 
cause the  patient  breathes  normally  and  the  gas  passes 
so  quietl}-  through  the  water  and  over  the  mucous 
membrane  of  the  nares  and  pharynx  as  to  warm  it 
properly. 

The  specialist  who  limits  his  practice  to  extracting 
teeth  under  nitrous  oxid  anoBstbesia  usually  manufac- 
tures his  own  nitrous  oxid.  When  this  is  done  the 
nitrous  oxid  is,  of  course,  maintained  at  the  same  tem- 
perature as  the  atmosphere  of  the  operating-room,  and 
this  is  one  reason  why  he  gets  so  much  better  results 
than  the  man  who  relies  on  the  ordinary  gas  cylinder 
for  his  supply  of  nitrous  oxid. 

I  mav  be  mistaken,  but  it  is  mv  belief  that  much 


140  General  Ancestketics  in  Dentistry. 

of  the  struggling,  the  jactitation,  the  wild  dreams  and 
horrible  nightmares  experienced  so  frequently  during 
nitrous  oxid  anaesthesia  are  caused  by  the  cold  nitrous 
oxid  stimulating  the  nerves  of  the  bronchi  and  lungs 
and  they  in  turn  reflexly  communicating  with  the 
brain.  However  this  may  be,  I  do  know  that  with  the 
method  I  am  now  using  of  warming  the  gas  the  anaes- 
thesia resulting  is  quiet  and  peaceful  and  free  from 
dreams  or  visions  of  an  annoying  character. 


General  AncEsthetics  in  Dentistry.  141 


LECTURE  XII. 
Nitrous  Oxid  and  Oxygen. 

Oxygen  is  a  supporter  of  life,  but  nitrous  oxid  gas 
is  not.  Priestly  who  discovered  both  nitrous 'oxid  and 
oxygen  reported  some  very  interesting  experiments. 
He  placed  small  animals  under  two  receivers,  one  filled 
with  oxygen  and  the  other  air.  Those  under  the  re- 
ceiver filled  with  oxygen  lived  twice  as  long  as  those 
under  the  receiver  filled  with  air.  The  death  of  birds 
in  the  receiver  filled  with  oxygen  transpired  without 
convulsions  while  the  death  of  the  birds  in  the  receiver 
containing  air  was  always  accompanied  by  convulsions. 
The  heart  retains  its  irritability  for  hours  when  death 
takes  place  in  oxygen,  but  this  is  not  the  case  when 
death  takes  place  in  air. 

"Demarquay  immersed  two  kittens  in  water  and 
kept  them  there  until  they  had  lost  consciousness  and 
were  completely  asphyxiated.  One  had  been  previ- 
ously confined  for  twenty  minutes  in  a  glass  case  con- 
taining two  parts  oxygen  and  one  of  air,  the  other  had 
breathed  only  atmospheric  air.  On  removing  them 
from  the  water  there  was  only  a  slight  movement  of 
the  lower  jaw.  At  the  end  of  a  minute  and  a  half  the 
superoxygenated  kitten  arose  and  totteringly  walked 
around  and  made  an  uneventful  recoverv.     The  other 


142  General  Ancestheiics  in  Dentistry. 

partially  recovered  at  the  end  of  fifteen  minutes,  but 
died  the  next  day.  These  experiments  were  repeated 
a  number  of  times,  but  always  with  the  same  results." 
(Gwathmey.)  I  stated  in  the  last  lecture  that  nitrous 
oxid  when  inhaled  does  not  resolve  itself  into  its  com- 
ponent parts,  but  remains  as  nitrous  oxid.  If  you  add 
pure  oxygen  to  the  nitrous  oxid  gas  and  then  inhale  it, 
something  very  different  may  happen.  Some  of  the 
oxygen  inhaled  passes  into  the  blood  to  form  a  loose 
chemical  combination  with  the  red  corpuscles ;  oxy- 
hamaeglobin.  Life  in  this  way  can  be  supported  in- 
definitely, the  oxygen  supplying  food  for  the  blood, 
which  in  turn  feeds  the  tissues  while  the  nitrous  oxid  is 
anesthetizing  the  patient. 

Is  it  not  reasonable,  then,  that  I  should  recommend 
the  use  of  nitrous  oxid  gas  plus  oxygen  in  all  cases  in 
which  nitrous  oxid  is  indicated?  With  nitrous  oxid, 
the  period  of  available  anaesthesia  is  but  30  seconds ; 
with  nitrous  oxid  and  oxygen,  you  can  operate  as  long 
as  you  wish.  With  pure  nitrous  oxid,  when  all  air  is 
excluded,  "the  average  inhalation  period  is  fifty-six 
seconds ;  at  the  end  of  that  time,  fresh  oxygen  must 
be  admitted  or  permanent  asphyxia  will  result" 
(Hewitt)  ;  while  with  nitrous  oxid  and  oxygen,  in 
proper  proportions,  there  is  no  asphyxia.  All  deaths 
arising-  from  nitrous  oxid  are  supposed  to  have  been 
caused  by  asphyxia ;  no  death  has  ever  been  reported 
from  operations  performed  under  nitrous  oxid  and 
■oxygen.  The  clonic  muscular  spasms  or  "jactitation" 
so  comnion  under  nitrous  oxid  rarely,  if  ever,  occurs 
under  nitrous  oxid  and  oxygen. 


General  Anaesthetics  in  Dentistry.  143 

While  Andrews,  of  Chicago,  was  the  first  to  use 
nitrous  oxid  and  oxygen  as  an  anaesthetic,  Hillischer, 
of  Viei.na,  was  the  first  dentist  to  systematically  em- 
ploy nitrous  oxid  and  oxygen  in  definite  proportions. 
He  states  that  he  "has  administered  'Schlafgas'  to  pa- 
tients of  all  ages;  to  those  suffering  from  advanced 
affections  of  the  heart;  to  those  with  diseases  o£  the 
lunffs;  and  to  the  subjects  of  epilepsy  and  other  ner- 
vous diseases.  He  turther  states  that  he  looks  upon 
this  gaseous  mixture  as  absolutely  without  contra-in- 
dication — that  he  administers  it  to  every  patient  irre- 
spective of  any  morbid  state  which  may  be  present. 
He  admits  that  more  experience  is  needed  in  adminis- 
tering 'Schlafeas'  (nitrous  oxid  and  oxygen)  than  in 
giving  any  other  anaesthetic  with  which  we  are  ac- 
quainted ;  and  there  can  be  no  doubt  that  here,  again, 
he  is  correct."     (Hewitt.) 

Apparatus. 

All  modem  nitrous  oxid  appliances  are  so  arranged 
that  oxygen  can  be  administered  in  combination  with 
nitrous  oxid  gas  in  definite  proportions.  This  is  ac- 
complished by  the  addition  of  a  cylinder  of  oxygen  at- 
tached to  the  appliance  in  a  convenient  position.  A 
second  rubber  bag  is  used  to  contain  the  oxygen. 
These  appliances  have  a  "mixing-chamber."  The 
nitrous  oxid  gas  passes  from  its  cylinder  into  its  rubber 
bag  and  from  thence  into  the  mixing-chamber.  The 
oxygen  passes  likewise  from  the  oxygen  cylinder  into 
tlic  oxygen  bag,  from  which  it  finds  its  way  also  into 


144  General  Ancesthetics  in  Dentistry. 

the  mixing-chamber.  The  two  gases  combine  here  in 
the  proportions  desired. 

There  is  a  device  so  adjusted  that  the  amount  of 
oxygen  passing  out  of  the  oxygen  bag  can  be  con- 
trolled or  regulated.  Although  not  scientifically  accu- 
rate, it  is  an  advance  in  the  right  direction. 

The  amount  of  oxygen  necessary  to  prevent  cyano- 
sis and  muscular  spasm  varies  somewhat  with  the  in- 
dividual. If  we  rely  upon  the  oxygen  in  the  air  to  over- 
come spasm  and  cyanosis,  so  much  air  is  necessary  that 
it  prevents  anaesthesia.  On  an  average,  it  requires 
about  8^"  of  oxygen,  and  in  order  to  abstract  that  nmch 
oxygen  from  the  air  it  would  require  40"^°  of  air.  It 
requires  about  92^°  of  nitrous  oxid  to  anaesthetize  a 
patient  deeply,  so  it  is  evident  that  if  we  admit  40^° 
of  air  in  order  to  obtain  8'^°  of  oxygen,  we  have  left  only 
60"/'°  of  nitrous  oxid,  which  is  about  A2'^°  short  of  the 
average  amount  necessary  to  induce  deep  anresthesia. 
In  other  words,  in  the  40'^°  of  air  which  must  be  inhaled 
along  with  the  nitrous  oxid  in  order  to  furnish  8*^°  of 
oxygen  there  is  32*^"  of  nitrogen  that  we  do  not  need 
at  all.  It  is  evident,  then,  that  when  we  utilize  the  air 
to  furnish  the  requisite  8^°  of  oxygen,  we  have  only 
60^''  of  nitrous  oxid  for  anaesthetic  purposes,  but  when 
we  admit  8^°  pure  oxygen  direct  from  a  cylinder  we 
then  have  92^°  of  nitrous  oxid  for  the  purpose  of  induc- 
ing anaesthesia. 

It  has  been  my  experience  that  just  a  little  air  ad- 
mitted along  with  nitrous  oxid  is  disadvantageous.  It 
prolongs  the  induction  of  anaesthesia,  increased  excite- 
ment results,  and  there  is  more  jactitation,  lividity  and 


General  Ancesthetics  in  Dentistry.  145 

cyanosis  with  moderate  percentages  of  air  than  when 
all  air  is  excluded.  Hewitt's  experiments  show  that 
patients  can  be  anaesthetized  when  air  is  admitted  up  to 
30%.  But  with  30%  of  air  it  required  148  seconds  to 
induce  anaesthesia.  With  33%  of  air  he  failed  to  induce 
anaesthesia.  With  3%  to  5%  of  air  the  average  inhala- 
tion period  was  69  seconds.  He  concludes  by  saying: 
"So  far  as  the  general  results  of  these  cases  are  con- 
cerned, the  investigation  showed  that  with  percentages 
of  air  between  14  and  22  a  very  distinct  improvement 
was  manifest  over  the  ordinary  nitrous  oxid  cases. 
With  percentages  below  14  and  above  22  the  improve- 
ment in  general  results  was  less  marked.  The  conclu- 
sion at  which  the  author  arrived  in  the  course  of  this 
investigation  was  that  the  best  definite  mixture  for 
men  was  one  containing  from  14-18%  of  air,  while  the 
best  for  women  and  children  was  one  containing  from 
18-22%  of  air." 

It  is  well  to  remember  that  the  higher  the  percent- 
age of  air  admitted,  the  longer  it  will  take  to  induce 
anaesthesia  and  the  lighter  will  be  the  resultant  anaes- 
thesia, not  on  account  of  the  oxygen  that  is  abstracted 
from  the  air,  but  on  account  of  the  smaller  amount  of 
nitrous  oxid  that  enters  the  lungs  with  each  inhalation. 

It  becomes  very  much  easier  and  far  more  accurate 
to  rely  upon  oxygen  in  a  cylinder  than  to  depend  upon 
abstracting  oxygen  from  the  air.  By  thus  administer- 
ing nitrous  oxid  and  oxygen,  excluding  all  air,  patients 
can  be  surgically  anaesthetized  indefinitely.  Teters, 
of  Cleveland,  recently  anaesthetized  a  large,  obese  and 
plethoric  patient,   for  a  curettement  and   ovariotomy. 


146  General  Ancesthetics  in  Dentistry. 

the  patient  being  under  the  influence  of  nitrous  oxid 
and  oxygen  for  two  hours  and  forty-eight  minutes, 
without  one  breath  of  air.  Nearly  600  gallons  of  ni- 
trous oxid  and  80  gallons  of  oxygen  were  used. 


Administration. 

Nitrous  oxid  and  oxygen,  unfortunately,  is  the  most 
difficult  of  all  anaesthetics  to  administer.  It  is  with- 
out doubt  the  safest  of  all  anaesthetics  and  but  for  the 
difficulties  attending  its  administration  would  be  the 
most  popular  and  most  generally  used  of  all  ana?s- 
thetics.  I  have  already  spoken  of  the  difficulties  inci- 
dent to  administering  pure  nitrous  oxid,  and,  in  addi- 
tion to  these,  we  have  the  added  responsibility  of  feed- 
ing the  oxygen  in  the  right  proportions  at  the  right 
time.  It  is  som.ething  that  must  be  learned  by  repeated 
admin>trations.  The  more  familiar  you  are  with  ad- 
ministering pure  nitrous  oxid  the  quicker  will  you  be- 
come proficient  in  administering  this  combined  anaes- 
thetic. 

Just  as  with  pure  nitrous  oxid,  some  individuals  and 
some  types  are  more  susceptible  than  others.  People 
enjoying  robust  health,  strong  and  muscular,  full- 
blooded  and  active  are  not  as  favorable  subjects  as 
the  frail,  the  physically  weak,  and  those  of  tranquil 
temperament.  All  people  who  drink  or  smoke  to  ex- 
cess, whether  coffee,  tea  or  liquors,  drug  fiends  and 
alcoholics,  and  those  addicted  to  cigarettes  and  chew- 
ing tobacco  are  more  difficult  to  anaesthetize  by  this 
method  than  those  of  temi)or.'itc  habits. 


Gemral  Anaesthetics  m  Dentistry.  147 

Much    depends,    of    course,    on    proper    breathing; 

hence  stenoses  and  obstructions  of  any  kind  whatso- 
ever in  the  mouth,  nose,  pharynx,  larynx,  trachea,  bron- 
chi or  the  lungs  interfere  more  or  less  with  inducing 
comfortable  and  successful  anaesthesia.  At  times  when 
the  patient  does  not  succumb  to  the  ansesthetic  as 
quickly  as  usual,  showing  signs  of  distress  and  discom- 
fort, an  examination  will  often  disclose  hypertrophied, 
turbinated  bones ;  deviated  sceptum ;  nasal  polyp  or 
polypi;  enchondroma  or  osteoma  in  the  nares ;  adeno- 
ma or  other  growths  in  the  pharynx;  cleft  palate,  hard, 
soft  or  both ;  odoematous  or  elongated  uvula  ;  enlarged 
tonsils;  enlarged  thyroid  gland;  impaired  lungs,  or 
lungs  restricted  in  their  action  by  adhesions,  the  result 
of  former  inflammatory  affections  or  the  presence  of 
pus  cavities  or  encroachment  on  the  lungs  of  various 
enlargements  and  tumor  formations.  The  anaesthetic 
itself  is  not  always  to  blame  for  imperfect  anaesthetiza- 
tion. 

When  a  prolonged  anaesthesia  is  to  be  induced,  the 
patient  must  be  as  carefully  prepared  as  for  ether  or 
chloroform.  Everything  that  has  been  said  in  regard 
to  the  chair,  the  assistant,  the  mouth-prop,  suggestion, 
arrangement  of  instruments,  etc.  in  the  lecture  on  ni- 
trous oxid  is  applicable  here.  All  these  matters,  as 
insignificant  as  they  may  appear  to  you,  must  be  ob- 
served if  you  wish  to  be  successful  in  administering 
nitrous  oxid  and  oxygen  for  dental  purposes. 

While  a  good  assistant  is  essential  to  success  with 
pure  nitrous  oxid,  with  nitrous  oxid  and  oxygen  it  is 
imperative.     Hundreds  of  nitrous  oxid  appliances  have 


Closed — Ready  to  Carry. 


ov 


The   Hrfjwn  An;t'slhctizer. 


General  Ancesfhefics  in  Dentistry. 


149 


Ready  to  Administer  Xitrous  Oxid  and  Oxygen. 


Inhaler. 


Chloroform  and  Ether  Attachment. 


150  General  Ancesthctics  in  Dentistry. 

been  discarded,  others  literally  thrown  out  of  the  office 
by  discouraged  and  often  disgusted  operators,  because 
of  failure  to  get  satisfactory  results,  the  supposed  fault 
not  being  with  either  the  nitrous  oxid  and  oxygen  or 
with  the  appliance,  but  mostly  because  of  lack  of  in- 
telligent assistance. 

All  preliminary  arrangements  having  been  made, 
the  patient  is  now  ready  to  be  an?esthetized.  The  "O"" 
bag  should  be  filled  about  two-thirds  full  of  oxygen 
and  the  "NO"  bag  about  two-thirds  full  of  nitrous 
oxid.  Place  the  inhaler  over  the  mouth  and  nose 
with  the  anaesthetic  shut  off.  Have  the  patient  breathe 
deeply  and  evenly  two  or  three  times  to  test  the  valves 
and  to  see  that  the  adjustment  is  such  as  to  exclude 
all  air.  You  judge  by  the  sound  of  the  valves  as  tO' 
whether  they  are  in  good  working  order.  Satisfied 
on  this  point,  the  anaesthetic  may  now  be  admitted. 
Turn  the  oxygen  indicator  to  ''1"  at  first,  then  "2,"  and 
as  the  anaesthesia  advances,  to  "4"  or  "6"  gradually. 
If  you  should  begin  with  "6"  or  "8,"  the  patient  would 
manifest  signs  of  restlessness  and  excitement. 

The  frail,  the  delicate  and  the  anaemic  will  admit 
of  oxygen  in  larger  proportion  in  the  beginning  than 
the  vigorous,  the  plethoric  and  the  athletic.  With  the 
average  patient  you  can  advance  the  indicator  five 
points  in  about  thirty  seconds,  and  in  fifty-nine  or 
sixty  seconds  to  "8."  The  indication  for  more  oxygen 
is  the  color  of  the  face.  If  the  face  assumes  a  dusky 
hue,  the  indicator  may  be  advanced  still  further.  In 
the  absence  of  duskiness  and  a  tendency  on  the  part  of 
the  patient  to  laugh  or  cry  or  move  the  hands  and  legs,, 


General  Ancesthetics  in  Dentistry.  151 

the  indicator  should  be  set  back  a  number  or  two.  It 
is  important  that  the  amount  of  oxygen  in  the  "O"  bag 
should  be  equal  to  the  amount  of  nitrous  oxid  in  the 
"NO"  bag.  If  this  is  not  the  case,  the  nitrous  oxid 
will  have  more  force  behind  it  than  the  oxygen  and 
the  proportions  can  not  be  maintained.  As  already 
mentioned  in  a  previous  lecture,  there  should  be  no- 
conversation  allowed  while  anaesthetizing  the  patient. 
Sounds  are  exaggerated,  and  the  sense  of  hearing  re- 
mains intact  till  the  close  of  the  third  stage  and  with 
some  patients  is  not  lost.  Talking  back  and  forward 
between  the  operator  and  the  assistant,  "do  this  and 
do  that,"  is  enough  to  defeat  any  anaesthesia.  Sugges- 
tions to  the  patient  in  a  low,  quiet,  but  firm  tone  of 
voice,  looking  to  the  quieting  of  the  patient  is  the 
only  conversation  permissible  during  the  induction  of 
anaesthesia.  If  I  wish  more  oxygen,  "O"  is  made  with 
the  thumb  and  first  finger;  if  more  nitrous  oxid,  two 
fingers  are  raised,  representing  an  "N."  If  I  wish  the 
oxygen  reduced,  an  "O"  with  the  fingers  and  one  nod 
of  the  head  at  the  same  time  means  set  the  oxygen 
indicator  back  one  notch,  two  nods  two  notches,  etc. 
An  "N"  with  the  nod  of  the  head  means  a  reduction 
in  flow  jof  the  gas,  two  nods  a  greater  reduction.  Two 
persons  soon  learn  to  work  together  with  signals  as 
successfully  as  a  base-ball  battery.  The  longer  the 
anaesthesia,  the  more  oxygen  will  the  patient  consume 
as  the  anaesthesia  progresses.  Different  appliances  may 
vary  somewhat,  but  with  the  Brown  an^sthetizer  I 
find  about  "8"  per  cent,  or  rather  when  the  indicator 


152  General  Anaesthetics  in  Dentistry. 

is  at  "8,"  I  get  the  best  results,  on  the  average,  in 
dental  operations. 

For  a  simple  case  of  extraction,  say  two  or  three 
teeth,  for  which  it  would  require  fifty  seconds  to  obtain 
an  available  anjesthesia  of  thirty  to  thirty-five  seconds 
with  pure  nitrous  oxid,  an  administration  of  nitrous 
oxid  and  oxygen  for  a  period  of  about  one  hundred 
and  ten  to  one  hundred  and  fifteen  seconds,  would 
afiford  an  average  available  anaesthesia  of  about  forty- 
five  seconds.  The  patient  in  the  former  case,  in  which 
pure  nitrous  oxid  was  administered,  would  be  cyan- 
otic and  on  the  border  line  of  dangerous  asphyxia;  in 
the  latter  case,  enough  oxygen  would  be  inhaled  to 
prevent  all  cyanosis  and  asphyxial  symptoms. 

The  First  Stage  of  nitrous  oxid  and  oxygen  does 
not  vary  materially  from  the  first  stage  of  pure  nitrous 
oxid. 

The  Second  Stage  is  more  prolonged  than  the  sec- 
ond stage  of  pure  nitrous  oxid,  because  the  patient 
does  not  lose  consciousness  as  quickly.  Respiration 
frequently  becomes  very  rapid  and  deep,  and,  if  the 
patient  shows  signs  of  excitement,  too  much  oxygen  is 
being  inhaled  and  the  amount  should  be  reduced.  As 
anoesthesia  deepens,  the  stertor,  incident  to  the  last 
part  of  the  second  stage  of  nitrous  oxid  anaesthesia,  is 
replaced  by  gentle  snoring;  the  dusky  cyanotic  condi- 
tion of  the  pure  nitrous  oxid  stage  is  wanting  and  in 
its  place  a  normal  complexion. 

The  Third  Stage,  or  the  Stage  of  "Surgical  Anaes- 
thesia," is  the  one  in  which  the  difference  is  more 
marked.     Instead  of  deep   cyanosis  and  loud  stertor, 


General  AncBsthetics  in  Dentistry.  153 

the  patient  has  the  appearance  of  one  in  a  natural  sleep, 

and  even  the  gentle  snoring  of  the  second  stage  disap- 
pears. The  breathing  is  regular  and  quiet.  You  will 
remember  in  the  lecture  on  nitrous  oxid  that  I  called 
your  attention  to  the  fact  that  the  tongue  became  en- 
larged on  account  of  engorgement  of  venous  blood, 
and  suggested  that  if  the  tongue  was  engorged  the 
same  condition  must  be  present  in  a  greater  or  less  de- 
gree throughout  the  respiratory  tract.  This  swelling 
of  the  tongue  does  not  take  place  when  anaesthesia  is 
induced  by  nitrous  oxid  and  oxygen,  and,  of  course,  the 
breathing  would  be  less  interrupted,  and  in  case  the 
patient  should  happen  to  have  adenoids,  enlarged  ton- 
sils, polypi,  etc.  (such  conditions  being  very  common) 
there  would  not  be,  the  same  inconvenience  and  danger 
as  would  be  assumed  in  administering  pure  nitrous 
oxid.  In  this  stage,  the  pulse  is  strong,  but  not  as 
rapid  or  small  as  the  pulse  in  the  third  stage  of  pure 
nitrous  oxid.  It  is  very  much  more  like  the  normal 
pulse,  just  as  the  breathing  and  the  complexion  is 
more  nearly  normal. 

The  eyelids  instead  of  being  rolled  back,  exposing 
the  eyeballs, -are  usually  closed.  The  pupils  remain 
more  nearly  normal  than  otherwise,  and  the  cornea 
is  generally  sensitive  to  touch,  and  does  not  lose  its 
sensitiveness  during  brief  anaesthesias. 

The  signs  of  ant'esthesia  are  very  much  the  same  as 
those  of  chloroform.  The  arm  if  raised  falls  limp.  The 
breathing  is  usually  quiet  and  regular,  and  sometimes, 
by  listening  closely  indistinct  snoring  may  be  detected, 
the  degree  depending  somewhat  on  the  normality  or 


154  General  Anaesthetics  in  Dentistry. 

abnormality  of  the  respiratory  channel.  The  conjunc- 
tival reflex  is  lost,  and  the  eyeballs  are  fixed  or  may 
move  slightly  from  side  to  side,  but  in  a  much  milder 
degree  than  is  found  in  anaesthesia  induced  by  pure 
nitrous  oxid. 

The  Fourth  Stage  in  nitrous  oxid  and  oxygen  anaes- 
thesia is  wanting.  The  toxic  dose  of  this  anaesthetic  is 
not  known.  Not  to  my  knowledge  has  there  ever  been 
a  death  reported.  I  have  tried  to  conceive  in  what  way 
or  b}^  what  means  death  could  come  under  nitrous  oxid 
and  oxygen  properly  administered.  Surely  not  from 
asphyxia  as  in  pure  nitrous  oxid  narcosis ;  not  from 
protoplasmic  poisoning  as  with  chloroform ;  not  by 
respiratory  paralysis  as  with  ether.  For  purely  dental 
purposes,  elminiating  fright  and  all  psychical  causes, 
eliminating  a  tooth  lodging  in  the  trachea  or  shock,  the 
result  of  blood  collecting  in  the  throat,  both  of  which 
are  incidental  causes  only,  I  can  not  conceive  of  death 
occurring  as  the  result  of  administering  nitrous  oxid 
and  oxygen. 


General  Ancssthetics  in  Dentistry.  155 


LECTURE  XIII. 
Nitrous  Oxid  and  Oxygen  in  Operative  Dentistry. 

^Vith  most  dentists,  the  word  anaesthesia  is  synony- 
mous with  extracting  teeth.  Ask  the  average  dentist  if 
he  uses  general  anaesthetics  and  he  will  say,  "No,  I 
do  not  extract  more  than  three  or  four  teeth  a  month 
in  my  practice  and  have  no  use  for  antesthetics."  If 
anaesthetics  meant  no  more  to  me  than  the  mere  extrac- 
tion of  teeth,  I  would  not  have  prepared  these  lectures, 
I  can  assure  you.  The  dental  surgeon  should  use  anaes- 
thetics in  all  painful  conditions.  One  of  our  most 
eminent  oral  surgeons,  Dr.  G.  V.  I.  Brown,  told  me 
recently,  that  if  he  should  resume  the  general  practice 
of  dentistry  he  would  use  nitrous  oxid  a  thousand  times 
where  formerly  he  had  used  it  but  once.  The  possi- 
bilities of  this  ansesthetic,  especially  in  combination 
with  oxygen,  had  not  been  realized  until  he  was  called 
upon  to  use  it  so  often  in  his  oral  surgery  practice. 

In  what  class  of  cases  would  I  use  nitrous  oxid 
and  oxygen?  In  all  painful  conditions  the  dentist  is 
called  upon  to  treat:  Sensitive  cavity  preparation;  re- 
moval of  pulps,  either  alive  or  surgically  after  an  arsen- 
ical application  has  been  made ;  shaping  teeth  for 
crowns  or  abutments  whether  alive  or  devitalized,  for 
in   one  instance  they  are   exquisitely   sensitive,   in   the 


Teter  Hospital  Apparatus. 

For  the  Administration  of  Nitrous  Oxid  and  Oxygen  and  Other 

General   Anaesthetics. 


Central  Ancesthetics  in  Dentistry.  157 

other  the  grinding  and  cutting  is  more  wearing  on  some 
patients  than  a  real  "hurt" ;  adjusting  cervical  or  pain- 
ful clamps;  treating  pyorrhoea;  rapid  wedging  of  the 
teeth  to  gain  space  for  fiUing;  opening  into  teeth  af- 
fected with  pericementitis  or  acute  alveolar  abscess; 
lancing  abscesses;  opening  into  pulps  for  the  purpose 
of  making  an  arsenical  treatment — in  short,  all  pain- 
ful or  fatiguing  operations  on  the  teeth.  Once  familiar 
with  operating  under  anaesthesia  you  would  relinquish 
dentistry  rather  than  practice  as  you  are  now  doing. 
You  may  think  3^ou  know,  but  you  do  not  know  the 
first  letter  in  the  word  "gratitude,"  nor  will  you  know 
till  you  have  looked  into  the  eyes  and  faces  of  your 
patients  when  they  leave  the  chair  after  using  nitrous 
oxid  and  oxygen. 

The  most  sensitive  cavities  can  be  prepared,  the 
most  painful  conditions  rendered  absolutely  painless 
by  this  method.  It  is  seldom  necessary  for  the  patient 
to  lose  consciousness ;  it  is  a  stage  of  analgesia  rather 
than  anaesthesia,  the  patients  once  in  a  while  momen- 
tarily passing  into  unconsciousness. 

Have  the  patient  understand  she  is  not  to  be  hurt, 
that  the  whole  matter  is  under  her  control.  Adjust  the 
rubber  dam,  insert  the  mouth-prop,  apply  the  nasal 
inhaler,  the  nitrous  oxid  and  oxygen  passing  through 
warm  water,  as  explained  in  the  last  lecture.  Instruct 
the  patient  to  raise  the  hand  if  she  feels  pain ;  keep  up 
a  running  conversation  with  the  patient  like  this :  "Am 
I  hurting  you?  Do  you  feel  pain?  Do  you  mind  what 
I  am  doing?  Are  you  asleep?"  etc.,  etc.  You  can 
keep  patients  in  this  condition  indefinitely,  and   they 


158  General  Anesthetics  in  Dentistry. 

will  be  resuscitated  in  two  minutes  after  discontinuing 
the  anesthetic  and  leave  the  office  bouyant  and  happy, 
not  dreading  to  return  for  the  next  appointment.     And 
the  operator — that  all-gone,  all-used-up,  collapsed  feel 
ing,  that  five  o'clock  feeling,  is  gone  to  return  no  more. 

The  rubber  dam  adjusted,  you  need  only  the  nasal 
inhaler.  Instruct  the  patient  to  breathe  rather  deeply 
the  first  four  or  five  inhalations,  then  assume  natural 
breathing.  Begin  by  breaking  down  enamel  walls  with 
a  chisel  or  proceed  gently  with  a  bur,  the  hand  to  be 
raised  if  pain  is  felt,  if  the  operation  is  the  preparation 
of  a  carious  tooth.  If  the  patient's  face  shows  the 
slightest  cyanosis,  indicate  oxygen,  and  have  the  as- 
sistant place  the  indicator  at  "2"  or  "3" ;  this  is  usually 
sufficient,  but  varies  with  the  individual.  Maintain 
this  a  while  if  the  patient  does  not  become  cyanotic 
again.  If  the  patient  shows  a  tendency  to  laugh,  or 
manifests  signs  of  stimulation,  diminish  or  discontinue 
tlie  oxygen.  It  is  simply  a  matter  now  of  administer- 
ing just  enough  of  the  combination  to  get  results.  If 
you  find  the  patient  going  down  too  deeply,  discon- 
tinue or  diminish  the  anaesthetic  for  a  few  inhalations, 
^'ou  will  soon  learn  the  stage  in  which  to  operate,  by 
practice. 

All  that  has  been  said  about  preparation  of  the  pa- 
tient is  applicable  here.  A  light  breakfast  or  a  light 
lunch  must  be  insisted  upon.  Loosen  all  bands,  have 
the  corset  removed,  and  the  bladder  should  be  empty. 
When  you  know  in  advance  that  you  are  to  operate 
unrler  anaesthesia,  the  patient  can  be  instructed  in  re- 
gard to  loose  clothing  and  dress  accordingly. 


General  Ancesthetics  in  Dentistry.  15!) 

An  anaesthetic  clinic  is  the  most  difficult  of  all  clin- 
ics in  which  to  get  satisfactory  results,  and  men  who 
see  anaesthetics  administered  at  clinics  only,  have  little 
appreciation  of  what  can  be  accomplished  in  the  quiet 
of  an  office  with  proper  surroundings.  Everything 
depends  upon  the  tranquillity  of  mind  that  can  be  in- 
duced, and  there  is  little  chance  for  this  in  a  public 
clinic.  If  the  patient  is  a  woman,  the  possibilities  of 
saying  or  doing  something  improper  tends  to  excite- 
ment and  restlessness  of  mind  rather  than  quiet  and 
composure. 

One  of  the  most  successful  public  anaesthetic  demon- 
strations I  have  ever  witnessed  was  conducted  by  Dr. 
Jessie  Ritchey  DeFord,  of  Des  Moines,  at  the  Fourth 
Annual  Alumni  Clinic  of  the  College  of  Dentistry, 
State  University  of  Iowa,  Iowa  City,  February  4th. 
1907.  The  operator  had  never  operated  upon  teeth 
before  under  anaesthesia.  His  clinic  was  to  make  a 
porcelain  inlay  in  an  upper  right  cuspid  labial  surface, 
gingival  cavity.  The  tooth  was  so  sensitive  that  the 
patient  could  not  stand  even  drying  it  with  absorbent 
cotton.  He  objected  to  taking  nitrous  oxid  and  oxygen 
because,  on  a  previous  occasion,  he  was  made  very  sick 
from  ether.  He  had  three  other  cervical  cavities  and 
finally  consented  to  take  the  anaesthetic  under  two 
conditions.  The  first  was  that  the  preparation  of  the 
cavity  should  be  painless,  and,  second,  that  all  four 
cavities  should  be  prepared  for  fillings  if  he  found  he 
was  not  being  hurt.  The'  doctor  proceeded  with  the 
anesthesia  as  I  have  descrilied,  and  the  patient,  a  den- 


160 


General  Ancesthetics  in  Dentistry. 


tal  student,  at  no  time  lost  consciousness,  and  when  the 
first  cavity  preparation  was  completed  said,  "Go  on 
with  the  next  one,  I  am  not  being  hurt,  I  am  having 
the  time  of  my  Hfe,"  and  during  the  twenty-five  min- 


The  Nevius  Nitrous  Oxid  Inhaler. 

utes  consumed  in  cavity  preparation,  he  never  once 
raised  his  hand  to  indicate  he  was  feeling  pain,  and  said 
a  dozen  times,  "I  am  not  minding  it,  there  is  no  pain, 
go  ahead."    He  made  this  request,  however,  "My  throat 


General  Ancesthetics  in  Dentistry.  161 

is  getting  cold,  please  add  more  warm  water."  Here 
was  a  patient  that  had  no  confidence  in  the  anaesthetic 
for  such  operations,  and  an  operator  who  was  naturally 
embarrassed  and  timid,  having  never  before  operated 
under  an  anaesthetic,  or  at  a  clinic,  yet  the  result  was, 
as  I  have  described  it,  and  you  can  hardly  imagine  a 
more  trying  ordeal  for  the  anaesthetist.  The  same 
anaesthetist  later  in  the  day  induced  a  thirty-minute 
anaesthesia  at  the  University  Hospital  with  nitrous 
oxid  and  oxygen  for  an  operation  on  the  soft  palate 
performed  by  Dr.  G.  V.  I.  Brown. 


162  General  Ancesthetics  in  Dentistry. 


LFXTURE  Xl\. 
Ethyl  Chloride. 

Physicians  have  long  sought  an  anaesthetic  agent 
as  quick  in  its  action  as  nitrous  oxid,  as  free  from 
danger  as  nitrous  oxid,  with  as  little  after  disturbance, 
yet  one  with  which  a  longer  period  of  ana?sthesia  could 
be  obtained  without  the  cumbersome  apparatus  incident 
to  nitrous  oxid  narcosis. 

Ethyl  chloride  when  first  introduced  was  supposed 
to  be  the  long-waited-for  agent  so  devoutly  desired. 
This  anaesthetic  was  first  used  by  Heyfelder,  in  1848. 
In  1880,  a  committee  of  the  British  Medical  Association 
after-  experimenting  on  animals,  rendered  an  adverse 
report,  and  its  use  was  abandoned.  In  the  year  1895, 
Carson  and  Thiesing  revived  ethyl  chloride  and  it  was 
used  by  some  extent  by  dentists.  This  same  year 
Soullier,  of  Lyons,  reported  its  use  in  8,417  clinical 
cases  without  a  fatality.  The  first  real  scientific  work, 
however,  is  said  to  have  been  done  by  Lotheisen  and 
Ludwig  in  Prof,  von  Hacker's  clinic  in  1897-98. 

McCardie,  in  1902-03,  studied  the  value  of  this 
drug  in  620  general  narcoses  and  is  enthusiastic  in  his 
praise  of  this  agent,  claiming  that  it  contains  all  the 
requisites  of  a  perfect  anjesthetic;  and  these  we  find 
set  forth  by  Tuttle  as : 


General  Anaesthetics  in  Dentistry.  1(53 

1.  Safety. 

2.  Insensibility   to   pain. 

3.  Complete  relaxation. 

4.  Easy  and  rapid  production  of  effect. 

5.  Freedom  from  dangers  and  disagreeable  after- 
effects. 

6.  Simplicity  of  administration. 

Tuttle  believes,  too,  that  these  facilities  are  nearly 
all  inherent  in  ethyl  chloride.  (Alontgomery  and 
Bland  in  Jour.  A.  M.  A„  April  2,  1904.)  Chemically, 
ethyl  chloride  is  one  of  the  haloid  substitutions  derived 
from  ethyl  alcohol,  and  it  is  formed  by  the  halogen 
element,  chlorine,  replacing  the  hydroxy  1  grouj)  in 
the  alcohol. 

Various  methods  are  employed  in  the  preparation 
of  this  agent,  but  those  most  frequently  used  are  as 
follows :  First,  by  passing  gaseous  hydrochloric  acid 
into  a  boiling  solution  of  zinc  chloride  in  twice  its 
weight  of  alcohol  (C,H50H+HCl=CoH,Cl  +HOH) ; 
second,  by  the  action  of  perchloride  of  phosphorus 
on  alcohol  (CoH^OH  PClsCl^HCl+PClgOCoH.Cl)  ; 
third,  by  the  action  of  chlorine  on  the  hydrate  of  ethyl. 

Those  who  claim  that  the  heart's  action  in  the  be- 
ginning is  increased  are  in  the  majority.  These,  how- 
ever, adm.it  that  the  circulation  returns  to  normal  as 
soon  as  anaesthesia  is  induced,  and  that  this  primary 
disturbance  is  due  to  nervous  excitement  rather  than 
direct  influence  of  the  drug,  an  experience  common  to 
the  administration  of  any  anaesthetic.  While  some 
have  soucht  to  show  that  arterial  tension  is  increased. 


164  General  Ancesthetics  in  Dentistry. 

others  are  as  positive  that  arterial  tension  is  dimin- 
ished. I  think  this  difference  of  opinion  has  arisen  be- 
cause some  investigators  have  experimented  during  a 
light  anaesthesia,  while  other  observers  have  made  their 
observations  during  deep  anaesthesia.  Wood  found 
that  upon  anaesthetizing  animals  to  a  deep  narcosis 
the  arterial  tension  was  lowered,  but,  when  the  anses- 
thetic  was  discontinued,  the  arterial  tension  regained 
the  normal;  so  it  is  possible  that  in  some  of  the  experi- 
ments that  have  been  reported  that  the  narcosis  was 
not  deep  enough  to  lower  arterial  tension. 

Koenig  not  only  believes  that  the  arterial  tension  is 
lowered  in  deep  ethyl  chloride  aneesthesia,  but  says  it 
is  due  to  the  influence  of  the  agent  on  the  pneumogas- 
tric,  because  it  disappeared  after  the  vagi  were  cut  in 
animals. 

Malherbe  and  Roubinovich  made  a  test  of  twenty- 
four  cases  with  Potain's  sphygmomanometer  to  ascer- 
tain the  action  of  ethyl  chloride  on  arterial  pressure  in 
man.  "Of  the  twenty-four  cases  examined  by  Alal- 
herbe  and  Roubinovich,  arterial  tension  was  decreased 
in  twenty-two,  and  the  frequency  of  the  pulse-beats 
followed  equally  the  modifications  in  the  degree  of 
arterial  pressure;  during  deep  sleep  diminishing  and 
increasing  and  attaining  finally  the  normal  number 
as  consciousness  was  restored." 

McCardie  concludes  that  the  pulse  is  slower  than 
normal  in  deep  anaesthesia,  but  that  its  regularity  is 
maintained. 

Montgomery  and  Bland  found  that  in  patients  with 
a   normal   circulatory   apparatus   there   was   usually  a 


General  Ancesihetics  in  Dentistry.  165 

slight  decrease  in  arterial  tension.  There  was  no  de- 
cided disturbance  in  the  pulse-beat.  At  the  beginning 
of  the  administration,  however,  there  was  a  certain  in- 
crease in  the  frequency  of  the  pulsations,  but  this,  of 
course,  was  due  to  the  psychic  disturbance  of  the  pa- 
tient, and  not  from  any  direct  action  of  the  drug.  The 
respirations  were  generally  stimulated  both  in  fre- 
quency and  depth. 

There  is  little  if  any  irritation  to  the  respiratory 
mucous  membrane  and  this  is  a  point  well  worth 
remembering,  as  collection  of  mucus  in  the  pharynx 
under  ether  aniBthesia  sometimes  almost  defeats  suc- 
cessful operating.  Another  feature  worthy  of  men- 
tioning is  that  the  tongue  does  not  swell  or  increase 
in  size  under  ethyl  chloride  anaesthesia  as  it  does  under 
nitrous  oxid  narcosis. 

Unfortunately  ethyl  chloride  narcosis  is  followed 
frequently  by  nausea,  and  but  for  this  disturbing  ele- 
ment would  be  far  more  popular  and  even  more  ex- 
tensively used  that  at  present. 

Headache  is  more  commonly  experienced  after  an 
administration  of  ethyl  chloride  than  after  an  adminis- 
tration of  nitrous  oxid  gas.  Another  thing  to  be  re- 
membered is  that  according  to  Luke,  ethyl  chloride 
has  an  affinity  for  the  masseter  muscle  and  the  spasm 
is  sometimes  so  severe  that  it  is  difHcult  to  find  a 
mouth-prop  that  will  withstand  the  strain. 

Safety. 

I  consider  ethyl  chloride,  in  careful  hands,  one  of 
the  safest  of  anaesthetics.     It,  of  course,  has  its  limita- 


166  General  Ancesthetics  in  Dentistry. 

t 
tions,  and  I  think  nearly  all  mortalities  reported  as  re- 
sult of  using  this  anaesthetic  have  been  due  to  care- 
lessness, improper  administration,  or  attempting  too- 
prolonged  an  anipsthesia.  Most  of  the  mortalities  re- 
ported have  occurred  abroad,  and  you  must  take  into 
consideration  that  "abroad"  means  always  that  the 
"closed"  method  has  been  employed. 

Soullier  and  Lyons  report  8,417  cases   without  au 
adverse  symptom.     Seitz  reports  but  one  death  in  16,- 

000  cases  collected  by  him,  and  this  death  occurred  in 
a  case  in  w^hich  ethyl  chloride  was  contra-indicated.. 
Ware  reports  one  death  in  8,207  cases,  and  the  death 
was  probably  the  same  one  reported  by  Seitz.  Mc- 
Cardie  asserted  "that  it  was  the  safest  of  all  anaesthet- 
ics except  nitrous  oxid,  and  that  the  death  rate  might 
be  placed  at  one  in  many  hundred  thousand."  He  ha& 
since  somewhat  modified  his  views,  but  as  late  as 
March  17th,  1906,  in  The  British  Medical  Journal,  says  : 
"Fortunately,   in  an   experience  of  nearly  2,000  cases 

1  have  not  seen  either  asphyxia  or  syncope  during  its 
administration."  Again,  he  says:  "Since  1897,  ethyl 
chloride  has  been  very  rapidly  growing  in  popularity, 
so  much  so,  indeed,  that  it  has,  unfortunately,  largely, 
and  in  some  places  altogether  replaced  nitrous  oxid. 
For  in.stance,  in  the  General  Flospital,  Birmingham, 
the  latter  is  rarely  used  at  all  save  in  the  dental  depart- 
ment. The  reasons  for  tiiis  popularity  are  those  that 
make  chloroform  so  favored  :  ethyl  chloride  is  rather 
pleasant  to  inhale,  is  non-irritating  to  the  air-passages, 
and,  more  than  all,  it  is  most  pleasant  and  easy  to  ad- 
minister." 


General  Ancesthetics  m  Dentistry.  16/ 

Weissner  states  that  in  Von  Hacker's  clinic  in 
Innsbruck,  that  ethyl  chloride  is  used  when  ether  and 
chloroform  are  contra-indicated  in  high  degrees  of  cir- 
culatory interruption,  fatty  degeneration  of  the  heart, 
diseases  of  the  respiratory  organs,  persons  enfeebled 
by  great  loss  of  blood  and  those  suffering  from  nerve 
shock. 

Luke,  of  Edinburgh,  in  his  "Guide  to  Ansesthetics"' 
says :  "In  the  past  two  years  ethyl  chloride  has  made 
enormous  strides  in  this  country  and  bids  fair  to  be  the 
most  frequently  employed  anaesthetic  which  we  possess. 
It  has  almost  completely  displaced  nitrous  oxid  in  gen- 
eral surgery."' 

Luke  places  the  death  rate  at  one  in  12,000.  Lothei- 
son  thought  ethyl  chloride  to  be  "quite  harmless,"  and, 
in  April,  1902,  reckoned  the  mortality  to  be  one  in 
17,000. 

Administration. 

There  are  two  grades  of  ethyl  chloride  on  the  mar- 
ket :  one  is  employed  as  a  local  anaesthetic,  and  the 
other  as  a  general  anaesthetic.  Carefully  discriminate 
between  the  two  varieties.  One  variety  is  very  much 
purer  than  the  other  and  is  intended  to  be  inhaled.  It 
makes  no  particular  difference  if  the  purer  variety  hap- 
pens to  be  sprayed  on  a  given  part,  but  it  makes  a 
great  difference  if  the  variety  that  is  made  to  be  used 
as  a  local  anaesthetic  should  happen  to  be  inhaled.  I 
soon  learned  in  using  ethyl  chloride  locally  for  opera- 
tions in  the  mouth,  that  much  of  the  anaesthetic  effect- 
obtained  wns  due  to  the  inhalation  by  the  patient  of 


168  General  Ancesthetics  in  Dentistry. 

the  vapor  that  was  sprayed  on  the  parts  locally,  and 

only  the  variet^^  that  is  manufactured  for  general  anaes- 
thetic purposes  should  ever  be  used  in  locations  where 
the  vapor  can  be  inhaled. 

Ethyl  chloride  may  be  obtained  in  capsules  and  in 
tubes.  The  tubes  usually  contain  about  sixty  cubic 
centimeters,  but  the  quantity  varies  with  the  different 
manufacturers,  and  some  manufacturers  make  two  or 
more  sizes.  The  larger  tubes  are  fitted  with  a  spray 
attachment.  These  tubes,  some  of  them  at  least,  are 
graduated  so  that  the  amount  of  material  being  used 
for  anaesthetic  purposes  can  be  seen.  For  the  purposes 
of  general  anaesthesia,  the  ethyl  chloride  is  sprayed 
from  these  tubes  into  an  inhaler.  The  capsules  are 
made  of  glass  and  usually  contain  from  three  to  five 
cubic  centimeters  hermetically  sealed. 

ihere  are  a  number  of  inhalers  on  the  market  and 
these  are  so  arranged  that  ethyl  chloride  can  either  be 
sprayed  into  the  inhaler  or  one  of  the  capsules  frac- 
tured and  its  contents  discharged  upon  a  piece  of  gauze 
arranged  for  that  purpose.  An  ethyl  chloride  in- 
haler may  be  improvised  by  modifying  somewhat 
an  Esmarch  chloroform  inhaler.  The  Esmarch  in- 
haler, as  you  will  recall,  consists  of  a  wire  frame 
over  which  is  stretched  a  piece  of  stockinet  or 
surgeon's  gauze,  which  extends  over  the  edges  arxd 
is  clamped  down.  Over  this  surgeon's  gauze  is 
stretched  a  piece  of  rubber  dam.  Clamp  the  rubber 
dam  down  with  the  gauze,  and  from  time  to  time  spray 
a  small  quantity  of  ethyl  chloride  on  the  gauze  lift- 
ing it  away  from  the  face  just  as  the  patient  completes 


Central  AruBSthetics  in  Dentistry.  169 

an  inhalation.  This  can  be  accomplished  while  the  pa- 
tient is  exhaling-,  and  does  not  interfere  seriously  with 
the  administration.  It  takes  longer  to  anaesthetize  a 
patient  and  more  material  is  used  than  when  employ- 
ing one  of  the  many  inhalers  supplied  by  the  dental 
and  surgical  dealers. 

Both  the  de  Trey  and  the  Stark  somnoform  inhalers 
are  excellent  ethyl  chloride  inhalers  also.  As  these 
appliances  and  their  use  are  described  in  the  somno- 
form lecture.,  it  will  not  be  necessary  to  refer  to  them 
in  this  lecture  except  by  name. 

In  the  administration  of  ethyl  chloride  we  have  the 
choice  of  two  methods;  namely,  first,  in  which  all  air 
is  excluded,  and  second,  in  Avhich  various  amounts  of 
atmospheric  air  is  admitted  to  the  lungs  along  with  the 
ethyl  chloride.  If  the  capsules  are  to  be  used  I  prefer 
the  Stark  inhaler,  but  if  the  large  tubes  are  selecte.i 
I  much  prefer  the  de  Tre}-  inhaler.  ]My  preference  in 
the  matter  is  the  Stark  inhaler  and  the  capsules. 

If  the  large  tubes  are  to  be  used,  place  the  appliance 
over  the  nose  and  face  and  have  the  patient  exhale  into 
the  bag  sufficient  air  to  distend  it.  During  the  second 
expiration  spray  into  the  appliance  through  the  apera- 
ture  about  two  c.  c.  of  ethyl  chloride.  With  breathing 
a  little  deeper  than  normal,  in  twenty  to  thirty  seconds 
light  anaesthesia  is  induced.  If  the  patient  is  large  and 
muscular,  after  four  or  five  inhalations  it  is  sometimes 
necessary  to  add  another  c.  c.  At  that  point  where 
consciousness  is  lost,  ''the  patient  often  quits  breath- 
ing for  from  five  to  twenty  seconds."  About  this 
time,  the  patient  may  become  stimulated  or  excited. 


170  General  Ancesthetics  in  Dentistry. 

move  the  feet  and  grab  at  the  bag.  Then  consciousness 
is  lost,  the  pupil  dilates,  the  eyeballs  roll,  and  the  res- 
piration becomes  deeper  and  slower.  At  this  stage, 
two  or  three  teeth  may  be  extracted  and  the  patient 
not  feel  the  pain ;  affording  a  working  period  from 
twenty  to  forty  seconds.  If  there  is  sufficient  anaes- 
thetic in  the  bag,  and  the  patient  is  permitted  to  breathe 
about  ten  seconds  longer,  we  get  a  very  profound 
anaesthesia  which  will  last  from  one  hundred  to  one 
hundred  and  twenty  seconds.  At  this  time,  the  corneal 
reflex  is  abolished,  the  face  reddens  slightly  and  some- 
times perspiration  appears  on  the  face.  If  the  anaes- 
thetic is  discontinued  at  the  end  of  the  first  stage,  the 
patient  awakes  suddenly  like  one  coming  out  of  a  hyp- 
notic sleep.  In  the  deeper  anaesthesia  just  described, 
most  patients  recover  quickly,  but  there  is  with  all  a 
dreamy  or  drowsy  stage  just  before  awaking,  and 
after  awakinp-,  with  many,  they  close  their  eyes  again 
for  a  secondary  nap  of  a  few  seconds.  Just  before 
awaking  is  the  time  when  neurotic  women  and  alco- 
holics make  trouble,  if  they  are  to  become  excited  after 
the  operation.  It  is  a  dangerous  procedure  to  try  to  for- 
cibly restrain  either  class  mentioned.  Neurotics  and  al- 
coholics occasionally  become  excited  going  under,  but 
ordinarily  it  is  just  before  awaking,  if  they  make  trou- 
ble at  all,  that  you  must  be  on  your  guard.  Do  not 
try  to  restrain  them  and  you  will  seldom  have  trouble. 
Cyanosis  is  a  rare  condition  during  ethyl  chloride 
anaesthesia,  and  if  it  should  l)c  present,  it  arises  not 
from  the   ethyl  chloride   itself,  but   rather  from    some 


General  Ancesthetics  in  Dentistry.  171 

mechanical  interference  of  the  respiration,  as  swallow- 
ing the  tongue. 

In  the  stage  of  light  anaesthesia,  there  are  seldom 
any  unpleasant  or  disagreeable  after-effects.  The  pa- 
tient is  awake  and  entirely  himself  in  about  a  minute 
from  the  time  the  first  inhalation  is  taken. 

Following  the  second  condition  described,  in  which 
the  anaesthesia  induced  was  of  a  very  profound  nature, 
nausea  and  headache  are  sometimes  present.  I  am  in- 
clined to  the  view  that  nausea  and  headache  following 
the  administration  of  ethyl  chloride,  when  the  "close 
method"  is  employed,  are  caused  not  so  much  from  the 
ethyl  chloride  itself,  but  is  rather  the  result  of  re-inhal- 
ing the  contents  of  the  rubber  bag. 

I  dare  say  if  the  de  Trey  inhaler  be  used  in  exactly 
the  same  manner  and  be  held  the  same  length  of  time 
over  the  nose  and  mouth,  and  a  given  number  of  pa- 
tients inhale  and  re-inhale  the  contents  of  the  bag, 
without  ethyl  chloride  being  added,  a  certain  number 
of  those  trying  the  experiment  will  experience  nausea 
a. id  headache.  Blood  entering  the  stomach  nearly  al- 
ways produces  nausea.  The  anaesthetic  should  not  be 
held  responsible  for  nausea,  the  result  of  swallowed 
blood. 

The  Stark  inhaler  is  so  arranged  that  the  amount 
of  anaesthetic  and  the  amount  of  air  entering  the  lungs 
can  be  very  accurately  gauged.  I  am  an  advocate  of 
the  open  method  in  administering  ethyl  chloride,  just 
as  I  prefer  the  admission  of  air  freely  in  the  adminis- 
tration of  ether,  chloroform  and  somnoform.  Take  a 
3  c.  c.  capsule  of  eth}-l  chloride,  place  it  in   its  com- 


172  General  Ancesthetics  in  Dentistry. 

partment  in  the  Stark  inhaler,  and  with  the  appliance 
in  position,  and  the  patient  ready,  fracture  the  tube. 
For  the  first  two  or  three  inhalations,  admit  all  air, 
then  just  a  little  ethyl  chloride,  then  a  little  more, 
then  a  little  more.  Now  all  air  may  be  excluded  and 
the  patient  permitted  to  breathe  once  or  twice  and 
usually  an  available  anzesthesia  of  about  ninety  seconds 
can  be  obtained.  You  can  regulate  the  depth  of  the 
anaesthesia  to  suit  the  operation  to  be  performed.  Nau- 
sea and  headache  following  the  administration  of  ethyl 
chloride  with  an  admixture  of  air  is  less  frequent  than 
when  all  air  is  excluded.  As  ethyl  chloride  is  adminis- 
tered in  the  same  kind  of  an  appliance  as  somnoform 
and  both  preparations  are  sold  in  the  same  kind  of 
containers  and  in  the  same-sized  tubes  and  capsules, 
the  reader,  for  a  more  minute  description  of  the  ad- 
ministration of  ethyl  chloride,  is  referred  to  the  lecture 
on  administration  of  somnoform. 

As  the  difficulties  and  dangers  encountered  in  ethyl 
chloride  administration  are  also  the  same  as  those  aris- 
ing from  somnoform  anaesthesia,  these  will  be  found  to 
be  very  fully  discussed  in  the  somnoform  lectures. 


General  Ancesihefus  in  Dentistry.  173 


LECTURE  XV. 
Somnoform. 

We  are  indebted  to  Dr.  G.  Rolland,  of  Bordeaux, 
France,  for  the  ancesthetic  mixture  which  he  has  named 
somnoform.  In  1895,  Dr.  Holland  organized  the  Bor- 
deaux Dental  -School,  and  to  him  was  assigned  the 
chair  of  anaesthesia.  Not  being  satisfied  with  the 
aniESthetics  in  general  use  for  dental  purposes,  he  ex- 
perimented with  various  anaesthetic  mixtures  till  1899, 
when  he  made  public  the  results  of  his  research.  He 
maintained  that  an  ideal  anaesthetic  should  be  one  that 
"would  enter  into,  sojourn  in,  and  make  its  exit  from 
the  organism  in  the  same  manner  that  oxygen  does; 
that  the  tension  of  the  an£esthetic  agent  should  be 
greater  than  that  of  oxygen  in  order  that  it  might 
take  the  place  of  oxygen  in  the  lung  alveoli;  and  that, 
according  to  the  laws  of  the  physiology  of  respiration, 
tension  produces  two  classes  of  phenomena  which  al- 
ternate and  are  opposed  to  each  other,  namely,  absorp- 
tion and  elimination,  and,  as  the  degree  of  volatility  of 
a  gas  determines  its  pressure,  the  more  volatile  a  gas, 
the  more  easily  it  can  be  absorbed,  and  consequently 
the  more  easily  it  can  be  made  to  take  the  place  of 
oxygen." 

Just  as  the  red  blood  corpuscles  are  charged  with 


174  General  Anoesihetics  in  Dentistry. 

oxygen,  during  inhalation  and  distributed  to  the  tissues 
so  will  somnoform  be  absorbed.  It  is  estimated  that  it 
takes  about  thirty  seconds  from  the  time  the  blood 
leaves  the  lungs  charged  with  oxygen  until  it  returns 
laden  with  carbon  dioxide.  A  given  red  corpuscle, 
then,  would  have  fed  out  all  of  its  oxygen  in  about 
fifteen  seconds.  Rolland  argued  that,  as  the  oxygen 
of  the  blood  is  consumed  in  about  fifteen  seconds,  the 
ideal  anaesthetic  should  be  as  rapid  in  its  action,  and 
experimented  along  that  line. 

In  the  chloride  of  ethyl,  we  have  an  anaesthetic 
agent  almost  as  rapid  in  its  action  as  somnoform,  but 
no  doubt  Rolland  satisfied  himself  that  this  agent  was 
not  volatile  enough  and  had  too  high  a  death  rate. 
Bromide  of  ethyl  evidently  did  not  meet  his  approval. 
This  latter  agent  is  not  as  volatile  even  as  the  ethyl 
chloride.  Methyl  chloride  is  more  volatile  than  either 
of  these  agents  and  no  doubt  is  added  to  the  ethyl 
chloride  and  the  ethyl  bromide  on  account  of  its  rapid 
evaporation,  thus  increasing  the  tension  of  somnoform 
and  causing  it  to  be  more  rapidly  absorbed  and  more 
quickly  eliminated.  It  is  said  that  methyl  chloride 
volatilizes  at  twenty  degrees  below  zero,  and  it  is  this 
agent  that  makes  somnoform  so  volatile. 

.Somnoform  is  composed  of 

Ethyl  Chloride  60% 

Methyl  Chloride  35% 

Ethyl   Bromide  5% 

I  am  inclined  to  think  that  this  is  a  mechanical  mix- 
lure  rather  than  a  chemical  compound.  By  exclud- 
ing all  air,  ancesthesia  can  be  induced  in  about  fifteen 


General  Ancestheiics  tn  Dentistry.  175 

seconds.  I  belie\'e  this  to  be  due  to  the  diffusibility 
of  the  methyl  chloride.  The  methyl  chloride  possesses 
anaesthe^ic  properties  of  its  own,  and  of  the  three  agents 
would  naturally  evaporate  quicker  than  the  others, 
carrjnng  some  of  their  vapor  along  with  it.  In  the 
matter  of  volatility,  the  ethyl  chloride  comes  next,  and 
serves  to  prolong  the  ansesthesia,  and  the  ethyl  brom- 
ide would  naturally  evaporate  more  slowly  than  the 
others,  maintaining  the  anaesthesia  as  the  other  agenis 
would  be  more  rapidly  eliminated. 

We  know  that  with  nitrous  oxid  the  average  induc- 
tion period  is  forty-four  seconds,  and  the  average  avail- 
able period  of  anaesthesia  is  thirty  seconds,  while 
with  somnoform,  when  all  air  is  excluded,  the  induction 
period  is  from  fifteen  to  thirty  seconds,  and  the  period 
of  available  anjesthesia  from  sixty  to  three  hundred 
seconds. 

I  have  noticed  in  using  the  large  somnoform  tubes 
that  after  two  or  three  anaesthesias  have  been  induced 
the  bromide  odor  becomes  more  pronounced,  and  when 
nearly  empty  the  odor  is  almost  that  of  pure  ethyl 
bromide,  and  it  is  from  this  fact  that  I  have  come  to 
believe  that  somnoform  is  not  a  chemical  compound, 
but  a  mechanical  mixture,  and  that  each  ingredient  is 
inhaled  in  proportion  to  its  volatility.  I  do  not  mean 
by  this  that  the  patient  gets  at  first  all  or  nothing  but 
methyl  chloride,  then  the  eth^d  chloride,  and  after 
these  the  ethyl  bromide,  because  the  methyl  chloride 
no  doubt  carries  some  of  the  vapor  of  both  of  these 
agents  along  with  it ;  but  I  do  believe  that  in  a  general 
way,  with  somnoform,  we  get  an  anaesthesia  character- 


J76  General  Ancesthetics  in  Dentistry. 

istic  of  each  agent  in  a  modified  form.  For  instance, 
there  is  less  muscular  spasm  during  somnoform  anaes- 
thesia than  in  the  anassthesia  induced  by  ethyl  chloride ; 
there  is  less  nausea  following  somnoform  anaesthesia 
than  with  etliyl  chloride  or  ethyl  bromide  alone ;  som- 
noform anaesthesia  is  more  tranquil  than  ethyl  chlor- 
ide anaesthesia,  somnoform  anaesthesia  is  superior  in 
every  respect  to  the  anaesthesia  induced  by  either  ethyl 
bromide  or  ethyl  chloride. 

As  to  safety,  somnoform  outclasses  both  ethyl 
chloride  and  elhyl  bromide,  and  it  difficult  to  explain 
why  there  should  be  such  a  discrepancy  in  the  mortali- 
ties incident  to  these  anaesthetics.  Ethyl  chloride  and 
ethyl  bromide  are  administered  almost  universally  by 
physicians  and  professional  anaesthetists,  the  patient 
having  been  prepared  in  advance;  while  somnoform  has 
been  administered  mostly  by  dentists,  many  of  them 
purchasing  appliances  and  administering  it  without 
any  experience  whatever.  Dental  salesmen  were  sent 
out  from  ahnost  every  dental  depot  in  the  United 
States,  and  actually  instructed  dentists  in  the  use  of 
somnoform ;  many  of  these  salesmen,  prior  to  this,  had 
never  seen  an  anaesthetic  administered ;  yet,  when  you 
compare  the  death  rate  of  these  anaesthetics,  two  being- 
administered  almost  entirely  by  physicians  and  pro- 
fessional anesthetists,  and  the  other  by  inexperienced 
dentists  and  traveling  salesmen,  the  results  obtained 
are  almost  beyond  belief.  The  death  rate  of  ethyl 
chloride  is  estimated  at  about  one  in  twelve  thousand. 
The  death  rate  of  ethyl  bromide  is  one  in  about  five- 
thousand  administrations.    Combining  these  two  anaes- 


General  Ancesihetics  in  Dentistry.  177 

thetics  with  methyl  chloride  in  the  proportions  men- 
tioned we  have  somnoform,  with  a  mortality  of  four 
in  one  million  administrations,  and  in  two  of  these 
mortalities  the  anaesthetic  was  not  held  responsible. 

It  might  almost  seem  that  I  am  mistaken  in  saying 
that  somnoform  is  a  mechanical  mixture,  but  rather 
that  it  is  a  chemical  compound,  the  safety  of  which  is 
infinitely  greater  than  the  safety  of  its  constituent 
parts.  I  have  been  asked  hundreds  of  times  if  I  con- 
sidered somnoform  as  safe  as  nitrous  oxid  gas.  This  is 
rather  a  difficult  question  to  answer.  The  answer  can 
not  be  given  "yes"  or  "no"  without  going  somewhat 
into  details.  If  all  air  is  excluded  in  administering 
nitrous  oxid  gas,  Hewitt  says,  the  average  time  in 
which  dangerous  asphyxia  is  produced  is  fifty-six  sec- 
onds. This,  he  also  says,  is  the  average  time  of  com- 
plete anjBsthesia.  It  is  not  true  of  any  other  anaes- 
thetic with  which  I  am  acquainted,  that  the  stage  of 
surgical  anaesthesia  and  the  danger  point  is  the  same. 
We  are  always  in  danger,  then,  with  nitrous  oxid, 
according  to  Hewitt,  when  the  patient  is  surgically 
anaesthetized.  But,  before  we  reach  this  point  with 
nitrous  oxid,  the  distress  of  the  patient  is  so  great  and 
the  symptoms  so  alarming,  that  few  men  are  brave 
enough  to  really  ansesthetize  their  patients  and  opera- 
tions are  nearly  always  performed  before  surgical  anaes- 
thesia is  induced,  and  this  is  the  reason  that  so  many 
fail  with  nitrous  oxid  gas.  The  patient  feels  and  knows 
everything  that  is  done,  because  he  is  not  surgically 
anaesthetized.  Most  operations  under  nitrous  oxid 
are  performed  in  the  analgesic  rather  than  the  ances- 


178  General  Ancesihetics  in  Dentistry. 

thetic  stage,  and  a  large  number  are  absolute  failures, 
and  it  would  have  been  better  for  both  the  patient  and 
the  operator,  had  nitrous  oxid  not  been  administered. 
Discredit  is  brought  upon  a  good  anaesthetic  and  often 
upon  a  good  appliance  by  attempting  extraction  and 
surgical  operations  when  the  patient  is  not  surgically 
anaesthetized.  I  say  without  hesitancy,  that  I  con- 
sider the  stage  of  surgical  anaesthesia  induced  by  pure 
nitrous  oxid  as  dangerous,  and  even  more  so,  than  the 
stage  of  surgical  anaesthesia  induced  by  somnoform. 
I  will  also  add  that,  if  from  fear  you  stop  short  of  the 
stage  of  anaethesia  with  somnoform,  as  is  nearly  al- 
ways done  Vv^ith  nitrous  oxid,  you  can  accomplish  as 
much  again  with  somnoform  as  with  nitrous  oxid  and 
not  hurt  your  patient  or  have  them  struggle  and  resist 
as  they  do  under  nitrous  oxid. 

There  is  this  to  say  in  favor  of  nitrous  oxid,  that  the 
"leave-off"  symptoms  are  very  pronounced,  while  with 
somnoform  this  is  not  the  case.  There  is  no  cyanosis, 
no  jactitation,  no  rolling  of  the  eyeballs  or  stertorous 
breathing,  but  a  beautiful  tranquil  sleep  in  most  cases 
and  nothing  alarming  to  either  the  anaesthetist  or  any 
friend  that  may  be  present.  Approaching  anaesthesia 
can  always  be  told  when  somnoform  is  the  anaesthetic 
employed,  as  surely  as  when  nitrous  oxid  is  used;  but, 
when  surgical  anaesthesia  is  induced  with  somnoform, 
the  patient  is  in  a  condition  of  safety,  while,  when  the 
stage  of  surgical  anaesthesia  is  reached  under  pure  ni- 
trous oxid,  the  patient  is  dangerously  asphyxiated. 

You  can  produce  death  with  either  one  or  both  of 
these  anaesthetics  by  holding  the  inhaler  tightly  over 


General  Ancestheiics  in  Dentislry.  179 

the  nose  and  face  excluding  all  air,  but  with  proper  pre- 
cautions and  careful  watching  death  rarely  occurs 
under  any  anaesthetic.  In  more  than  four  thousand 
somnoform  anaesthesias,  1  have  never  witnessed  an 
alarming  or  dangerous  symptom. 

Somnoform  is  a  transparent  liquid  preparation  ready 
for  use,  in  glass  tubes  and  capsules,  sold  by  all  dental 
dealers,  the   tubes   contain   sixty  grammes,   while   the 
capsules  are  made  in  two  sizes,  one  containing  3  cubic 
centimeters  and  the  other  5  cubic  centimeters.    To  the 
tubes  or  bottles  is  attached  a  valve  by  means  of  which 
the  somnoform  is  sprayed  into  the  inhaler.    These  tubes 
have  a  centimeter  scale  on  the  side  and  the  distance 
from  one  division  line  to  the  other  contains  5  c.  c.     In 
spraying  into  the  inhaler,  the  tube  is  turned  valve  end 
down  and  held  in  a  perpendicular  position.     As  soon 
as  the  somnoform  steadies  itself,  you  note  its  position 
on  the  scale;  it  settles  in  the  bottle  as  it  is  sprayed  out. 
It  only  took  the  contents  of  two  of  these  tubes  to  con- 
vince me  that  the  capsules  must  be  preferable.    Unless 
the  entire  contents  of  one  of  these  tubes  is  used  in  two 
or  three  days'  time,  the  unused  portion  has  a  peculiar 
odor,  and  the  longer  it  remains  in  the  tube  the  more 
offensive  it  becomes.     I  thought  at  first  that  the  mate- 
rials forming  this  mixture  had  decomposed,  but  later 
it  occurred  to  me  that  the  valve  no  doubt  leaked  a  little 
and  that  the  more  volatile  constituents  of  the  somno- 
form were  evaporating  leaving  the  heavier  bromine  pro- 
portion.   This,  I  am  satisfied,  is  exactly  what  happens 
to  the  contents  of  the  60-gramme  tubes.    Upon  inquiry 
I  have  ascertained  that  those  dentists  who  complain 


180  General  Ancesihetics  in  Dentistry. 


A  Somnoform  Capsule. 


The  de  Trey  Somnoform  Inhaler. 


General  Aruesiheiics  in  Dentistry. 


181 


most  about  somnoform  producing   nausea  have   been 
using  the  large  tubes. 

Luke  says  that  ethyl  bromide  used  as  an  anaesthetic 


inuF.lt  WASHER 


RUBBER  WASHER 


THREADS  SCREW  INTO 
TOP  OF  BOTTLE 


KNIFK  i;i>GE  TO 
PERFORATE  MF.TAL  SEAL 


METAL  SEAL 


Somnoform  Tube. 

is  followed  by  nausea  in  forty-five  per  cent,  of  the  ad- 
ministrations made. 

There  is  a  more  serious  objection  than   nausea  to 
employing  the  60-gramme  tubes.    The  patient  is  prop- 


182 


General  AncEslhetics  in  Dentistry. 


erly  prepared  in  the  chair,  the  mouth-prop  is  in  posi- 
tion, the  forceps  arranged  in  the  order  in  which  they  are 
to  be  used,  and  it  only  remains  to  spray  the  required 
amount  of  somnoform  into  the  inhaler.  Lest  too  large 
a  quantity  be  sprayed  into  the  inhaler,  one  is  apt  to  be 
overcautious  and  fall  short  of  the  mark,  and  in  attempt- 


Position  Advised  Durin;i;  Early  Stages  of  Inducing  Anaesthesia. 
Anaesthetist  Behind  Patient. 


ing  to  add  more  later,  at  a  time  when  so  many  things 
are  on  one's  mind,  there  is  danger  of  adding  too  much 
and  over-an£esthetitizing  the  patient,  inducing  an  anzes- 
thesia  deeper  than  necessary  with  accompanying  nau- 
sea. The  capsules  are  hermetically  sealed,  there  is  no 
opportunity  for  leakage  or  decomposition  and  we  al- 


General  AruBstheiics  in  Dentistry.  183 

ways  know  the  exact  quantity  with  which  w^e  have  to 
deal.  For  a  period  of  three  years,  I  confined  myself  to 
the  use  of  the  5  c.  c.  capsules,  taking  it  for  granted  that 
with  that  amount  of  somnoform  I  could  get  a  better 
result  than  by  using  the  smaller  size. 

On  one  occasion  my  dealer  being  out  of  5's,  I  pur- 
chased 3's  and  have  used  them  almost  entirely  ever 
since.  Even  with  the  3's  I  am  confident  that  not  more 
than  half  of  the  contents  of  these  smaller  tubes  are 
used,  and  I  find  myself  wishing  that  the  manufactur- 
ers would  make  a  tube  containing  but  two  cubic  centi 
meters. 

Inhalers. 

There  are  several  somnoform  inhalers  on  the  mar- 
ket, but  I  have  had  a  personal  experience  Avith  only  two 
of  these,  the  de  Trey  and  the  Stark.  The  de  Trey  in- 
haler is  the  one  almost  universally  used  by  dentists. 
For  the  sake  of  description,  I  will  separate  the  de  Trey 
inhaler  into  three  parts,  the  face-piece,  the  body,  and 
the  bag. 

The  face-piece  consists  of  a  transparent  celluloid 
cone  and  an  inflatable  pneumatic  rubber  hood  or  rim. 
The  hood  is  detachable  from  the  cone  and  both  can  be 
sterilized.  The  hood  being  transparent,  the  color  of 
the  lips  can  alwa)^s  be  noted,  and  the  mouth-prop 
watched  to  see  that  it  retains  its  position. 

The  body  is  made  of  metal  and  consists  of  a  hori- 
zontal and  a  perpendicular  tube.  The  horizontal  tube 
contains  an  inner  tube,  w-hich  is  held  in  position  b}' 
means  of  a  rather  stiff  spring.     Pushing  the  inner  tube 


184 


General  Antcs'heiies   in  Dentistry. 


forward  opens  the  air  vents  on  the  side  and  the  apera- 
ture  on  top  through  which  the  capsule  is  broken. 

The  perpendicular  tube  contains  the  breaking  de- 


/  NFLATABLE  RUBBER  My\RGIN 


CAPSULE  OPENING 


CELLULOID  FACE  PIECE 

(AND  AIR  VALVE 
CIRCLE  SUPPORTING     \ 
'face  PIECE  \  AIK  VALVE 


TCLFSCOPINO  PORTION 
Ot  HORIZONTAL  CYLINDER 
VvmS'  I'LSHEDIN 
OI'tNSAIR  V.«,VES 
ANDCAPSULE  OPENING 


LOCK  FOR 
BEMOVABLE  CAP 


REMOVABLE  CAP 
SUPPORTING  SPRING  TO 
HOLD  LINT    —^ 


iijg 


De  Trey  Somnoforni  Inliaiei. 

vice  which  fractures  the  capsule  and  the  spiral  frame 
about  which  is  wrapped  the  absorbent  lint  that  holds 
the  released  somnoform.  The  rubber  bag  is  stretched 
tightly  over  the  end  of  the  i)cr])endicular  tube  exclud- 
ing all  air. 


General  Antcsihciics  in  Dentistry. 


185 


The  Stark  inhaler,  in  a  general  way,  resembles  the 
de  Trey  inhaler.  It  likewise  may  be  said  to  consist  of 
three  parts.  The  face-piece  is  made  of  metal  instead 
of  celluloid  and  this  permits  of  its  being  boiled  before 
and  after  use  just  as  any  other  sOrgical  appliance.  The 
rubber  hood  is  the  same  as  that  used  with  the  de  Trey 
inhaler.    Inside  of  the  Stark  metal  face-piece  is  soldered 


Device,   Inside  Inhaler,  for  Breaking  Capsules. 
Note  at  R  and  P. 


a  piece  of  metal  gauze.  When  somnoform  is  to  be  fol- 
lowed by  ether  or  chloroform,  a  piece  of  surgeon's 
gauze  is  placed  in  the  face-piece  on  the  metal  gauze. 
As  soon  as  the  patient  is  deeply  anaesthetized  with  som- 
noform, the  face-piece  is  detached  from  the  appliance 
and  now  becomes  an  ether  or  chloroform  inhaler,  the 
drop  method  being  employed.    The  change  can  be  made 


186  General  Anesthetics  in  Dentistry. 

in  the  fraction  of  a  second  and  the  ether  or  chloroform 
simply  dropped  on  the  surgeon's  gauze.  The  body  of 
the  Stark -appliance  in  no  way  resembles  the  body  of 
the  de  Trey  appliance,  except  in  shape.  In  the  hori- 
zontal tube  is  an  opening  on  each  side  for  the  admission 
of  air.  Just  back  of  the  air  holes  is  a  device  for  regulat- 
ing both  the  amount  of  air  and  the  amount  of  somno- 
form  that  shall  be  inhaled  by  the  patient.  This  device 
is  regulated  by  means  of  a  small  handle  or  lever  moved 
backward  or  forward  by  the  thumb  of  the  hand  that 
holds  the  inhaler.  By  means  of  this  simple  device  the 
amount  of  somnoform  inhaled  can  be  regulated  to  a 
certainty.  If  you  so  wish,  all  of  the  somnoform  can  be 
excluded  and  only  air  admitted.  The  patient  witli  the 
inhaler  in  position,  can  breathe  for  any  length  of  time 
desired  without  getting  so  much  as  a  trace  of  the  an- 
aesthetic. You  can  admit  just  an  odor,  at  first,  and  in- 
crease it  as  slowly  or  as  rapidly  as  you  desire  for  each 
individual  case.  The  amount  of  anaesthetic  inhaled  is 
absolutely  under  your  own  control.  More  than  this, 
when  the  patient  is  aneesthetized,  the  somnoform  can 
be  shut  in,  its  escape  prevented,  and  again  turned  on  at 
the  desired  time.  I  have  fractured  a  5  c.  c.  tube  of  som- 
noform in  my  Stark  appliance,  and  eighteen  minutes 
later  found  sufficient  remaining  in  the  bag  to  anaesthe- 
tize a  patient.  (See  cuts  pages  209-211.) 

On  the  back  of  the  perpendicular  tube  is  soldered  a 
smaller  brass  tube  just  the  size  to  hold  a  5  c.  c.  capsule 
of  somnoform.  Of  course,  if  it  holds  a  5,  it  will  also 
hold  a  3  c.  c.  capsule,  but  not  at  the  same  time.  The 
capsule  in  position,  the  cover,  another  brass  tube,  is 


General  Ancesthetics  in  Dentistry .  187 

placed  over  the  capsule,  and  when  the  patient  is  ready, 
slight  pressure  on  the  telescoping  tube  fractures  the 
capsule  and  the  contents  collect  on  the  absorbent  lint, 
or  surgeon's  gauze,  in  a  receptacle  beneath  made  for 
the  purpose. 

The  rubber  bag  is  of  the  same  kind  as  that  supplied 
with  the  de  Trey  inhaler. 

A  special  appliance  is  necessary  for  somnoform  on 
account  of  its  volatile  nature.  After  once  leaving 
its  capsule,  it  evaporates  so  rapidly  that  it  is  impossible 
to  confine  it  in  any  appliance  without  a  rubber  bag.  On 
one  occasion  I  went  with  an  oculist  to  the  residence  of 
a  patient  to  administer'  somnoform  for  an  eye  enu- 
cleation. Upon  ariving,  I  discovered  that  I  had  failed 
to  bring  the  rubber  bag.  We  tried  first,  holding  a  nap- 
kin over  the  bottom  of  the  appliance  where  the  bag  is 
attached  and  wasted  four  or  five  5  c.  c.  capsules.  Then 
we  tried  cotton  underneath  and  a  napkin  over  that  and 
wasted  two  or  three  more  5's  and  gave  up  in  disgust. 
The  next  day  we  returned  and  with  one  3  c.  c.  capsule 
induced  an  anaesthesia  sufficient  for  the  enucleation, 
and,  when  the  patient  returned  to  consciousness  the 
bandage  was  in  position,  the  last  pin  just  being  inserted. 

Ethyl  chloride  can  be  administered  without  a  bag; 
so  can  ethyl  bromide,  but  somnoform  must  be  con- 
tained. If  you  will  take  a  3  c.  c.  capsule  of  somnoform 
and  hold  it  a  little  higher  than  the  head  and  fracture  the 
point  by  striking  it,  the  fluid  will  not  hit  the  floor;  it 
will  vaporize  before  it  gets  that  far. 


188  General  Ancestheiics  in  Dentistry. 


LECTURE  XVI. 
Somnoform — Continued. 

Other  things  being  equal,  the  anaesthetic  that  dis- 
turbs physiological  functions  the  least  must  be  a  desir- 
able anaesthetic.  The  anaesthetic  agent  that  maintains 
the  pulse  rate  near  the  normal,  that  interferes  but 
slightly  with  respiration,  that  does  not  accumulate  in 
the  system,  that  does  not  alter  the  secretions  of  the 
kidneys,  that  does  not  change  the  blood  chemically,  that 
seldom  nauseates,  is  rarely  followed  by  headache  or  un- 
pleasant after-results,  and,  in  addition,  one  that  quickly 
an?esthetizes  and  is  quickly  eliminated  and  not  difhculr 
to  administer  is,  indeed,  an  auEESthetic  worthy  of  inves- 
tigation.    Such  an  anaesthetic  is  somnoform. 

A  patient  about  to  be  anaesthetized,  no  matter  how 
trivial  the  operation,  or  how  safe  the  anaesthetic  agent 
employed,  is  more  or  less  nervous  and  excited.  It  is 
seldom  that  a  patient  takes  the  dental  chair  to  be  anaes- 
thetized that  he  does  not  have  an  accelerated  pulse. 
Physicians,  accompanying  patients  to  my  office  to  wit- 
ness an  extraction  under  somnoform  anassthesia,  have 
frequently  called  attention  to  the  fact  that  a  pulse  of 
150  or  higher,  at  the  beginning  of  the  administration, 
falls  to  about  80  or  85  and  is  maintained  at  that  during 
the  operation.    In  other  patients,  the  pulse  may  not  beat 


General  AncBsihetics  in  Deniisiry.  189 

more  than  90  per  minute  upon  taking  the  chair,  but 
usually  quiets  down  to  a  little  above  normal.  While 
somnoform,  no  doubt,  increases  the  heart's  action  at  the 
beginning  of  the  anaesthesia,  I  am  inclined  to  believe 
that  a  pronounced  acceleration  is  the  result  of  nervous- 
ness and  anxiety  on  the  part  of  the  patient.  It  is  no  un- 
usual occurrence  for  the  pulse  to  increase  its  action  per- 
ceptibly and  sometimes  disastrously  during  an  exam- 
ination, for  life  insurance,  even  when  no  heart  abnor- 
mality is  present. 

There  are  a  few  patients  who  maintain  their  nervous 
equilibrium  to  such  a  degree  as  not  to  show  excitement 
when  about  to  be  aneesthetized.  The  pulse,  in  these 
exceptional  cases,  under  somnoform.  in  the  beginning, 
is  usually  augmented  ten  to  fifteen  beats  per  minute, 
but  when  completely  ansesthetized  resumes  the  normal, 
or  just  a  little  above  the  normal. 

My  experience  with  somnoform  has  shown  the 
pulse  to  be  more  of  an  ether  than  a  chloroform  pulse; 
full,  bounding  and  regular.  Somnoform  is  eliminated 
quickly,  the  patient  being  slightly  stimulated,  wonder- 
fully pleased,  talkative  and  bouyant.  Even  quiet  people 
talk  fluently,  and  good  talkers  for  several  minutes  will 
repeat  time  and  again  their  dream  or  experience  during 
anaesthesia,  amazed  and  delighted  at  the  result  obtained. 
I  recall  the  case  of  an  attorney  for  whom  I  extracted 
a  third  molar.  He  was  a  large  man,  weighing,  I  should 
say,  more  than  two  hundred  and  fifty  pounds.  I  ojier- 
ated  for  this  man  at  about  11  A.  ]\I.,  and  I  never  nad  a 
more  pleased  patient  in  my  life.  About  1  o'clock,  he 
returned  to  tlic  office  and  said  :  "T  wisli  again  to  thank 


190  General  Ancesthetics  in  Dentistry. 

you  for  the  operation  you  made  for  me  this  morning", 
and  I  wish  that  you  would  show  me  that  appliance;  I 
want  to  know  just  how  it  works."  This  is  only  one  in- 
stance of  the  appreciation  shown  by  nearl};-  everyone 
for  v/hom  I  have  operated  under  somnoform.  I  think 
I  may  safely  say  that  ninety-five  per  cent,  of  the  pa- 
tients to  whom  I  have  administered  somnoform  regain 
consciousness  in  a  state  of  comfortable  or  joyous  stim- 
ulation. They  can  not  thank  you  often  enough  and 
they  volunteer  to  send  all  their  friends  and  neighbors. 
I  recall  a  fine  old  gentleman  past  seventy-five  years  of 
age.  I  extracted  seven  teeth  for  him  under  somnoform 
anresthesia,  and  he  ran  his  hand  into  his  pocket  and  paid 
the  fee  before  he  left  the  chair.  He  remarked  that  his 
daughter  had  suffered  for  years  with  her  teeth,  and  he 
would  have  her  pay  me  a  visit.  The  next  day  she  ar- 
rived. She  remarked,  "Father  drove  home  from  your 
office,  alone,  thirteen  miles,  after  you  operated  for  him, 
put  his  horse  in  the  stable  and  came  direct  to  m_v  home, 
before  going  into  his  house,  to  tell  me  about  it" — an- 
other example  of  somnoform  stimulation. 

Rarely  does  anyone  become  exhausted  as  the  result 
of  somnoform  anaesthesia.  I  have  had,  perhaps,  a  dozen 
cases  in  which  I  allowed  the  patient  to  rest  a  few  min- 
utes before  leaving  the  office.  In  each  of  these  cases, 
T  administered  more  somnoform  than  necessary,  or  the 
])aticnt  was  more  than  ordinarily  susceptible  to  its  in- 
fluence. 

The  respiratior,  at  the  beginning  of  somnoforin  in- 
duction is  usually  what  the  anassthctist  makes  it.  By 
this   I   mean    that  the   patient  tries   to  breathe   as   in- 


General  Ancesthetics  in  Dentistry.  191 

siructed.  I  say  nothing  about  the  breathing  until  I 
ascertain  by  observation  the  respiration  of  the  patient. 
Very  seldom  is  it  necessary  to  make  any  suggestion 
in  regard  to  respiration.  By  giving  directions  in  ad- 
vance, the  patient  becomes  confused  and  alarmed  and 
breathes  every  way  but  the  way  you  desire.  Say  noth- 
ing and  you  will  succeed  far  better  than  by  giving  the 
minutest  instruction. 

Ordinary  respiration  is  sufficient  to  oxygenate  the 
blood,  and  ordinary  respiration  is  sufficient  to  somno- 
form  the  blood.  After  the  appliance  is  adjusted,  if  the 
]:)atient  continues  to  breathe  normally,  in  a  few  seconds 
the  respiration  will  become  deeper  and  slower.  Should 
this  occur  there  is  no  need  for  alarm,  it  is  physiological 
with  somnoform.  Should  the  patient  after  the  first  few 
inhalations  begin  to  take  shorter  and  shorter  breaths, 
amounting  almost  to  "panting,"  in  a  low,  firm  voice 
suggest  deeper  breathing.  If  short  respiration  is  con- 
tinued, remove  the  inhaler,  or  shut  ofif  all  som-noform 
until  normal  breathing  is  resumed.  With  the  kind  of 
breathing  described,  the  patient  is  more  apt  to  become 
asphyxiated  than  anaesthetized,  no  matter  what  anaes- 
thetic agent  is  employed. 

When  I  procured  my  first  somnoform  appliance,  I 
studied  the  directions  for  three  weeks  before  making  an 
administration.  My  first  patient  was  an  athletic  young 
fellow,  a  foot-ball  player,  who,  in  a  practice  game, 
fractured  his  left  central  and  lateral  incisors,  the  pulps 
remaining  in  position.  The  directions  that  came  with 
the  somnoform  appliance,  said,  ''Instruct  the  patient  to 
l")reathe  deeply,   and   when  tlie  first  exhalation  passes 


192  General  Ancesihefics  in  Dentistry. 

into  the  rubber  bag-,  break  the  capsule  and  exclude  all 
air.  As  I  had  administered  nitrous  oxid  for  more  than 
twenty  years,  I  thought  I  knew  what  deep  breathing 
meant,  so  I  showed  my  patient  in  advance  how  I  wished 
him  to  breathe.  He  did  just  as  L,  told  him.  The  first 
inhalation  he  received  all  air,  and  no  anaesthetic ;  on  the 
second  inhalation  the  air  was  shut  out  of  the  appliance 
and  he  received  all  somnoform  with  the  air  he  had  ex- 
haled into  the  bag.  His  head  fell  to  one  side  like  he  had 
been  hit  with  a  black-jack.  I  removed  the  pnlps  and 
then  took  out  my  watch  and  timed  him.  His  pulse  was 
strong,  his  respiration  a  little  deeper  than  normal,  and 
he  slept  as  quietly  and  as  peacefully  as  a  child  for  the 
period  of  six  minutes.  The  same  afternoon  a  girl,  four- 
teen years  of  age,  presented  with  the  lower  molars  on 
each  side  broken  down.  I  instructed  her  to  breathe 
about  half  as  deeply  as  the  young  man,  and  allowed  her 
to  take  three  inhalations  with  all  air  excluded,  extracted 
the  teeth  and  could  have  removed  others.  After  a  while 
I  learned  that  deep  breathing  was  not  essential  to  som- 
noform anaesthesia,  and  at  the  present  time,  as  inti- 
mated above,  prefer  normal  breathing  in  nearly  all 
cases. 

Occasionally  a  nervous  child  or  a  hysterical  woman, 
at  the  very  beginning  of  somnoform  induction,  will  hold 
their  breath  and  refuse  to  breathe.  The  longer  the 
breath  is  held,  the  deeper  will  be  the  next  inhalation. 
It  is  important  just  here  to  watch  closely.  The  inhaler 
should  be  removed  or  withdrawn,  as  it  would  be  dan- 
gerous to  inhale  pure  somnoform  at  the  next  inhalation. 
You  will  recall  that  many  patients  die  when  chloroform 


General  Ancesihetics  in  Dentistry.  '  193 

is  administered  when  only  two  or  three  inhalations  have 
been  taken.  The  vapor  was  too  strong  or  the  inhala- 
tions too  deep. 

It  is  evident  that  somnoform  does  not  accumulate  in 

the  system,  because  the  patient  recovers  consciousness 
very  quickly  no  matter  how  long  the  ansesthetic  state 
is  maintained.  My  longest  somnoform  anoesthesia 
lasted  twenty-five  minutes,  and  in  a  minute  after  re- 
moving the  inhaler  the  patient  was  wide  awake.  This 
was  a  case  of  crushed  fingers.  The  surgeon  thought 
five  minutes  would  be  ample  for  the  operation,  but  the 
case  proved  to  be  more  complicated  than  at  first  sup- 
posed. At  the  end  of  five  minutes  I  suggested  ether, 
or  chloroform,  but  there  was  neither  in  the  office  of  the 
physician,  and  the  operation  would  have  been  discon- 
tinued if  either  of  us  went  to  a  drug-store,  so  there  was 
nothing  to  do  but  continue  with  somnoform.  I  U-sed 
ten  5  c.  c.  tubes,  and  the  patient  left  the  office  in  less 
than  three  minutes  after  the  anjesthetic  was  discon- 
tinued. 

Dr.  Bronson,  a  dentist  residing  at  Gowrie,  Iowa, 
told  me  that  he  anaesthetized  his  sister-in-law  with 
somnoform  for  a  surgical  operation,  and  maintained 
surgical  anaesthesia  for  thirty-five  minutes.  I  had  an 
opportunity  to  talk  with  the  patient  and  had  her  give 
me  a  history  of  the  case.  She  had,  on  previous  occas- 
ions, been  ansesthetized  with  both  ether  and  chloroform 
and  was  in  a  position  to  make  a  comparison.  Slie  in- 
formed me  that  the  somnoform  anresthcsia  was  in  no 
way  unpleasant  and  that  she  awoke  just  as  she  did 
mornings  from  natural  sleep.     She  felt  no  pain  what- 


194  General.  A ncvsfhetics  in  Dentist ry- 

ever  during"  the  operation.  There  was  no  nausea,  such 
as  she  had  experienced  with  ether  and  chloroform.  The 
antesthetist  told  me  he  had  hardly  removed  the  inhaler 
when  she  was  wide  awake.  I  mention  these  cases  to 
show  that  somnoform  is  not  cumulative  in  the  sense 
that  ether  and  chloroform  are  cumulative.  I  have  had 
brought  to  my  notice  a  few  cases  where  patients  were 
drowsy  and  wanted  to  sleep  after  the  operation.  This 
is  common  to  chloroform  and  ether,  but  seldom  occurs 
as  a  sequence  to  nitrous  oxid  and  somnoform.  Hewitt 
mentions  a  case,  reported  to  him  by  a  physician,  oi  a 
patient  who  slept  for  three  days  after  an  anaesthesia  in- 
duced by  nitrous  oxid  gas. 

Dudley  Buxton,  the  English  anaesthetist,  says,  "Dr. 
Swain  has  examined  the  blood  of  patients  before  an'l 
after  taking  somnoform  and  found  no  change  in  the 
amount  of  haemoglobin  or  in  the  number  of  leucocites. 

Urinary  analyses  have  been  made  prior  to  and  at 
the  conclusion  of  somnoform  anaesthesia  and  no  alter- 
ation in  the  specific  gravity  or  nature  of  the  urine  has 
been  observed. 

Somnoform,  so  far  as  I  have  been  able  to  observe, 
do£s  not  irritate  the  mucous  membrane;  nor  does  it 
irritate  the  nerves  of  the  nares,  pharynx,  larynx,  tra- 
chea, bronchi  or  lungs.  Its  non-irritability  is  an  ele- 
ment of  safety  well  worth  mentioning.  From  the  fact 
that  it  does  not  irritate  the  mucous  membrane,  there 
is  an  absence  of  accumulation  of  mucus  in  the  throat, 
such  as  we  always  have  accompanying  the  administra- 
tion of  ether.  This  mucus  sometimes  almost  defeats 
surgical  anaesthesia,  and  the  anaesthetist  must  discon- 


General  Anaesthetics  in  Dentistry.  195 

tinuc  frequently  and  swab  out  the  throat  to  prevent 
suffocation. 

From  the  fact  that  somnoform  does  not  irritate  the 
nerves,  we  can  almost  eliminate  the  condition  kno'.vn 
as  Laryngo  Reflex,  "Syncope  of  Duret."  Irritating 
anjEsthetic  vapors  sometimes  refiexly  cause  paralysis 
of  the  respiration  and  circulation,  which  has  alreacl}' 
been  considered  in  a  previous  lecture  under  "Spasm 
of  the  Glottis." 

From  the  fact  that  somnoform  is  non-irritating  to 
the  respiratory  apparatus,  it  is  indicated  especially  in 
minor  surgical  operations,  and  for  all  patients  afSicted 
with  pulmonary  disorders. 

Nitrous  oxid  causes  enlargement  of  the  tongue 
and  the  soft  tissues  of  the  pharynx  and  throat  from 
venous  engorgement.  Patients  having  hypertrophied 
tonsils,  adenoid  vegetations  in  the  upper  pharynx,  en- 
larged or  oedematous  uvula  or  abnormal  growths  of 
the  throat  are  far  more  comfortably  ansesthetized  with 
somnoform  than  nitrous  oxid.  Nitrous  oxid  increases 
the  size  of  all  these  tissues,  already  abnormally  en- 
larged, while  there  is  no  change  in  the  size  of  the  tis- 
sues or  organs  named  when  somnoform  is  the  anaes- 
thetic agent  used. 

Nausea  is  not  a  very  common  occurrence  during 
or  following  somnoform  anfBsthesia.  Rolland  claims 
but  one  per  cent,  of  nausea,  while  Paden,  of  Chicago, 
claims  that  nausea  occurs  in  about  three  per  cent,  of  his 
cases. 

I  can  well  understand  how  some  men,  or  why  some 
men,  have  more  nausea  than  others.     Nausea  depenJs 


196  General  Anocsthetics  in  Dentistry. 

mostly  on  three  conditions :  First^  administering  an 
anaesthetic  on  a  full  stomach,  or  too  soon  after  eating. 
This  cause  I  will  eliminate,  because,  as  dental  surgeons 
operate  largely  for  patients  under  nitrous  oxid  and 
somnoform  just  when  they  happen  to  come  to  the  office, 
one  dentist  is  as  apt  to  get  patients  of  this  kind  as 
another.  Second,  some  operators  insist  on  a  deeper 
somnoform  anaesthesia  than  necessary.  This  is  a  mis- 
take that  most  men  make  with  somnoform  ;  they  anaes- 
thetize their  patients  deeper  than  is  necessary,  usually, 
for  the  operation  to  be  performed.  Where  but  one  or 
two  teeth  are  to  be  extracted,  an  anaesthesia  is  induced 
sufficient  for  double  the  amount  of  work  to  be  done. 
This  fallacy  can  be  corrected  only  by  experience.  It 
is  more  common  to  those  accustomed  to  administering 
nitrous  oxid  gas  than  to  those  who  have  not  had  ni- 
trous oxid  experience.  The  nitrous  oxid  man  has  ac- 
quired the  habit  of  strenuously  excluding  all  air  and 
having  the  patient  breathe  deeply.  The  habit  is  so 
fixed  it  is  difficult  to  modify  it.  Then,  the  nitrous  oxid 
man  has  been  accustomed  to  sucli  pronounced  "leave- 
off"  symptoms,  dusky  countenance  and  cyanosis,  loud 
stertorous  breathing,  jactitation,  etc.,  that  it  takes  him 
some  time  to  recognise  the  less  pronounced  somnoform 
anaesthesia  indications.  Over-anassthetization,  1  think, 
is  the  most  comivon  cause  of  nausea.  Third,  exclusion 
of  all  air  is  provokative  of  nausea,  also.  When  som- 
noform was  first  introduced  into  this  country,  the  di- 
rections advocated  that  only  one  inhalation  of  air  be 
taken,  then  to  exclude  all  air  and  breathe  deeply.  Two 
administrations  follovvin"-  the  directions  convinced  rac 


General  Anccsihetics  in  Deniisiry.  197 

that  a  safer  and  more  rational  method  should  be 
adopted  of  inducing  somnoform  anaesthesia,  and,  from 
that  day  to  this,  I  have  been  advocating  more  air  and 
normal,  or  just  a  little  more  pronounced  than  normal 
breathing. 

I  have  already  referred  to  natisea  following  the 
administration  of  somnoform  from  a  partially  used  60- 
gramme  bottle.  In  my  own  practice,  nausea  is  a  rare 
occurrence.  In  more  than  4,000  somnoform  aniesthc- 
sias  I  have  only  experienced  ten  cases  of  nausea  where 
blood  was  not  swallowed.  This  record  is  not  confined 
to  somnoform  anaesthesias  for  the  extraction  of  te^tli 
alone,  but  includes  somnoform  administration  for  re- 
moval of  tonsils,  amputation  of  fingers,  ingrowing  toe 
nails,  opening  abscesses,  lancing  felons,  vaginal  and 
uterine  operations,  and  for  various  minor  surgical  cases. 

I  recall  an  interesting  case  at  the  Methodist  Hos- 
pital. One  of  our  leading  surgeons  call'ed  upon  me 
to  "guarantee"  that  I  could  administer  somnoform  to 
one  of  his  patients  without  supervening  nausea.  Thi5 
patient  had  been  recently  operated  upon  and  had  been 
so  badly  nauseated  with  ether  that  severe  vomiting 
had  made  it  necessary  to  remove  the  stitches,  re-open 
the  wound  for  re-examination  and  reparation  of  dam- 
ages. He  insisted  that  it  would  not  do  to  have  this 
patient  nauseated  again;  she  probably  would  not  sur- 
vive. I  told  him  I  could  promise  nothing  in  such  a 
case,  but  was  confident  that  somnoform  would  be  less 
apt  to  nauseate  than  any  other  anresthetic.  He 
thoiight  that  a  five-minute  anesthesia  would  be  suffi- 
cient.    In  this  case,  the  lightest  anaesthesia  possible 


19S  General  Anesthetics  in  Dentistry. 

for  comfortable  operating  was  decided  upon.  I  asked 
one  of  the  nurses  to  take  the  patient's  hand,  and,  when 
the  patient's  hand  lost  its  grip  or  relaxed,  to  follow 
the  movements  of  the  hand  with  her  disengaged  hand. 
When  the  nurse's  hand  started  to  close,  I  knew  that 
the  patient  needed  more  an?esthetic  and  when  the 
nurse's  hand  was  relaxed,  I  knew  that  the  patient's 
hand  was  relaxed,  so  I  admitted  air.  The  patient's 
hand  was  .under  the  sheet  where  I  could  not  observe 
it.  With  this  test  for  surgical  anaesthesia,  I  held  the 
patient  under  somnoform  anaesthesia  for  a  period  of 
nine  minutes,  and  I  learned  afterwards  there  was  no 
supervening  nausea. 

Just  recently  a  young  girl  about  nineteen  years  of 
age  was  referred  to  me  for  an  extraction  under  somno- 
form anaesthesia.  Her  mother  told  me  that  she  would 
surely  become  nauseated,  that  even  the  smell  of  meat 
broiling  would  make  her  sick,  and  that  odors  .agreeable 
to  other  people  would  nauseate  her.  Of  course,  I  ex- 
])ected  nausea,  but  insisted  all  during  the  induction  of 
anaesthesia  that  she  would  not  be  sick,  and  she  was  not. 

An  elderly  lady  insisted  that  somnoform  would 
nauseate  her,  and  I  insisted  that  it  would  not.  Then 
she  told  me  that  on  a  previous  occasion  she  sufifered 
for  five  days  with  nausea  after  an  ether  anaesthesia, 
and  that  physicians  despaired  of  her  life.  After 
regaining  consciousness  she  swallowed  a  little  air  and 
belched  it  up,  but  did  not  succeed  in  emptying  her 
stomach.  I  said  to  her,  "There  is  no  use  trying;  you 
can't,  and  you  know  that  you  can't."  She  replied,  "I 
guess  I  can't."     T  'phoned  her  in  Ihc  afternoon  and  as- 


General  Ancesihetics  in  Dentistry.  199 

certained  that  she  had  not  been  the  least  bit  nauseated 
after  returning  home. 

I  could  relate  dozens  of  similar  cases  and  these 
have  convinced  me  that  somnoform  carefully  admin- 
istered with  an  abundance  of  air  seldom,  if  ever,  nau- 
seates. 

Blood  swallowed  nearly  always  produces  nausea, 
and  manv  cases  of  nausea  during  or  after  somnoform 
anaesthesia,  in  operations  about  the  nose,  throat  and 
mouth,  are  caused,  not  from  the  anaesthetic,  but  from 
the  blood  that  gravitates  into  the  stomach. 

Headache,  with  me,  following  somnoform  anaesthe- 
sia, is  so  rare  that  it  is  hardly  worth  mentioning.  1 
have  only  known  three  or  four  patients  to  complain 
of  headache  after  somnoform  anaesthesia.  If  others 
have  more  of  these  cases,  they  probably  arise  from 
rebreathing  with  the  air  excluded.  Carbon  dioxide 
accumulates  in  the  bag  and  carbon  dioxide  will  pro- 
duce headache  when  rebreathed. 


200  General  Ancesthetics  in  Dentistry. 


LECTURE  XVII. 
Somnoform  Administration. 

It  would  be  irksome  to  repeat  here  what  I  have  said 
in  a  previous  lecture  about  the  preparation  of  the  pa- 
tient, the  operating--chair,  the  assistant,  the  quiet  of  the 
room,  etc.,  yet  all  these  things  are  taken  for  granted 
in  what  I  shall  have  to  say  about  administering  som- 
noform. If  the  lecture,  "Elements  of  Success,"  has  not 
been  read,  let  me  suggest  that  this  lecture  be  deferred 
till  then,  because  what  I  am  to  say  now  about  admin- 
istering somnoform  can  not  be  successfully  accom- 
plished unless  the  details  already  referred  to  be  min- 
utely followed. 

There  are  several  ways  of  administering  somno- 
form, well  illustrated  by  the  following  narrative.  I 
gave  a  clinic  last  May  before  the  Nebraska  State  Den- 
tal Society.  A  gentleman  in  the  audience  evidently 
thought  that  his  method  of  administering  somnoform 
was  superior  to  mine,  because  he  asked  me  if  I  would 
permit  him  to  administer  somnoform  if  he  procured  a 
patient.  I  readily  consented.  He  went  to  the  hotel 
and  returned  with  a  traveling  salesman  of  Jewish 
nationality.  He  could  not  have  selected  a  much  more 
difficult  case.  The  patient  was  an  amusing  fellow  and 
persisted  in  giving  a  history  of  the  case  in  spite  of  all 


General  Anccsihetics  in  Dentisiry.  201 

we  could  do  to  keep  him  quiet.  He  claimed  to  live 
in  San  Antonio,  Texas,  and  said  that  he  had  been  in 
every  dental  office  in  Texas  to  have  that  tooth  ex- 
tracted and  he  had  never  met  a  man  before  who  would 
even  try  to  extract  it ;  that  his  tooth  was  'well  known  In 
Texas  and  they  all  advised  against  having  it  out. 
Examination  showed  the  tooth  to  be  an  unerupted 
upper  left  cuspid.  I  did  not  think  that  somnoform  was 
the  ansesthetic  indicated  for  this  case.  Had  it  come  to 
me  in  private  practice,  the  patient  would  have  been 
sent  to  the  hospital  and  ether  administered.  The  pa- 
tient was  made  ready  and  the  mouth-prop  inserted. 
The  inhaler  used  was  the  de  Trey.  The  operator 
placed  the  inhaler  over  the  nose  and  face  of  the  pa- 
tient, then  took  from  the  box  a  5  c.  c.  capsule  of  som- 
noform and  placed  it  in  the  aperture  made  for  that 
purpose.  Then  he  started  his  patient  breathing  a.s 
deeply  as  you  ever  saw  any  one  breathe  in  your  life, 
and  after  he  was  breathing  rythmicall}^  just  as  he 
exhaled,  the  dentist  fractured  the  somnoform  capsule 
and  excluded  all  air.  I  said  to  the  gentleman  next  to 
me,  "In  about  a  minute  you  will  see  something  interest- 
ing." In  less  than  a  minute  the  patient's  feet  were  in 
the  air,  he  knocked  the  inhaler  out  of  the  doctor's 
hands,  and  several  held  him  in  the  chair.  The  doctor 
was  about  to  begin  operating  when  I  grabbed  his  wrist  ■ 
and  asked  him  to  wait  a  moment.  I  assembled  the  ap- 
pliance which  in  the  skirmish  had  fallen  to  pieces,  and 
placed  it  over  his  face  again,  and  continued  the'  anaes- 
thetic. In  the  meantime  he  had  taken  several  inhalations 
of  air,  was  breathing  about  normally  and  took  the  som- 


202  General  Ancesthetics  in  Dentistry. 

noform  without  a  struggle  or  the  twitching  of  a  muscle 
of  his  face  and  I  put  him  down  very  deep  on  account  of 
the  nature  of  the  operation.  By  this  time  the  doctor 
was  calm  again  and  in  about  two  minutes  successfi^liy 
extracted  the  tooth,  and  the  patient  opened  his  eyes 
laughing  and  thought  he  was  at  the  hotel  riding  in  the 
elevator.  He  went  over  to  the  hotel,  wrote  out  a  de- 
scription of  the  case,  related  his  anaesthetic  experience, 
subjectively  commended  the  anaesthetist  and  the  opera- 
tor and  insisted  that  the  Nebraska  State  Dental  So- 
ciety should  send  a  letter  of  greeting  to  the  Texas 
State  Dental' Society  and  inform  them  that  his  tooth 
had  been  captured. 

This  method  was  new  to  me.  and  it  may  have  been 
a  good  one,  but  we  came  very  nearly  having  a  double 
failure.  When  the  doctor  commenced  to  operate  the 
iirst  time,  the  patient  was  not  surgically  anaesthetized 
and  had  he  attempted  or  continued  to  extract  at  the 
time  I  requested  him  to  wait,  he  would  have  failed 
to  have  made  a  successful  extraction,  and  the  anaesthe- 
sia would  have  proven  a  decided  failure,  and  we  would 
have  had  a  rough  house.  I  say  the  method  was  a  new 
one.  The  new  feature  was  to  place  the  capsule  in  its 
aperture  and  have  it  remain  there,  the  inner  barrel 
being  held  forward  with  the  thumb.  The  deep  breath- 
ing and  shutting  off  all  air  after  the  rubber  bag  had 
been  inflated  was  adhering  strictly  to  the  directions 
furnished  .with  somnoform  appliances  when  first  used 
in  America.  It  is  amazing  that  more  deaths  have  not 
occurred  from  somnoform,  and  the  only  thing  that  has 


General  Anaesthetics  in  Dentistry.  2U3 

prevented  them  is  the  remarkable  safety  of  the  anaes- 
thetic. 

Somnoform  is  the  easiest  of  all  anaesthetics  to  ad- 
minister. In  an  experience  of  more  than  four  years  and 
more  than  four  thousand  anaesthesias,  I  have  not  wit- 
nessed an  alarming  or  a  dangerous  symptom.  I  use 
both  the  de  Trey  and  Stark  inhalers,  but  prefer  the 
latter.  As  these  appliances  differ  in  construction, 
I  will  describe  the  use  of  each,  separately.  As  the 
de  Trey  inhaler  is  the  older  of  the  two,  we  will  dis- 
cuss that  first.  No  absolute  rule  can  be  formulated 
to  cover  all  cases  in  administering"  an  anesthetic,  as 
the  personal  equation  must  be  taken  into  consideration, 
no  matter  what  anresthetic  agent  is  employed.  It  is 
a  difficult  matter  to  explain  on  paper  how  to  administer 
an  anaesthetic.  It  is  an  easy  matter  when  I  have  a 
patient  in  the  chair,  because  the  method  is  adapted 
to  that  particular  case  and  those  looking  on  grasp  tlie 
situation,  or,  if  they  do  not  grasp  the  situation  or 
understand  why  the  details  vary  with  individual  cases, 
it  can  be  explained  at  the  close  of  the  anesthesia. 

In  order  to  simplify  matters,  let  us  say  that  the 
patient  to  be  anaesthetized  is  a  woman  about  thirt)^ 
years  of  age,  of  delicate  appearance,  weighing  about 
130  pounds,  anaemic,  of  quiet  demeanor,  the  operation 
being  the  extraction  of  an  upper  third  molar.  The 
tooth  is  not  a  very  difficult  one  to  extract.  We  have 
said  that  the  patient  is  anaemic,  and  this  is  the  keynote 
to  this  case.  You  can  anaesthetize  an  anaemic  patient 
a  little  more  rapidl}'  than  a  plethoric  patient  without 
discomfort. 


204  ■  General  Ancesihetics  in  Dentistry. 

Exclusion  of  Air. — The  more  common  method  in 
a  case  of  this  kind  is  to  exclude  all  air  or  nearly  ail 
air.  The  patient  is  seated  in  the  chair,  mouth-prop 
in  position.  She  is  instructed  to  breathe  rather  deep- 
ly. After  two  or  three  respirations,  the  inhaler  is 
placed  over  the  nose  and  mouth.  Remove  the  inhaler, 
turn  a  little  to  one  side,  fracture  a  somnoform  capsule, 
the  contents  of  which  escapes  on  the  gauze  in  the  re- 
ceiver of  the  appliance.  If  the  capsule  is  fractured 
when  the  inhaler  is  in  position  on  the  face,  the  report  is 
apt  to  startle  the  patient.  The  patient  is  still  breath- 
ing as  described.  Place  the  inhaler  again  over  the  nose 
and  face,  just  as  she  begins  to  exhale,  and  that  exhala- 
tion will  go  into  and  inflate  the  bag.  The  barrel  of  the  in- 
haler may  nov^^  be  pushed  forward  for  one  inhalation, 
in  which  event  the  patient  gets  about  one-third  sonmo- 
form  and  two-thirds  air.  Or,  if  the  barrel  is  not  forced 
in,  the  patient  is  inhaling  all  somnoform  with  the  ad- 
dition only  of  the  amount  of  air  that  was  exhaled  into 
the  rubber  bag  in  the  beginning.  With  a  3  c.  c.  capsule 
it  only  requires  about  three  inhalations  to  induce  a 
sufficiently  deep  anassthesia  for  the  kind  of  a  case  we 
are  now  discussing.  In  fifteen  to  thirty  seconds  ihe 
patient  can  be  aucesthetized  by  this  method. 

I  do  not  believe  that  this  method  should  be  used 
in  routine  work.  The  an?esthetic  effect  is  not  as 
pleasant  to  the  patient;  the  anesthesia  induced  i? 
nearly  alv/ays  more  profound  than  is  necessary:  the 
patient  is  more  apt  to  create  a  disturbance  in  the  begin- 
ning and  be  nauseated  afterwards;  and  it  is  certainly 


General  Ancesthetics  in  Dentistry.  205 

more  dangerous  than  the  method  which  I  will  next  de- 
scribe. 

Admission  of  Air. — The  mouth-prop  is  in  position 
and  the  patient  is  ready  to  be  anaesthetized.  Fracture 
a  3  c.  c.  somnoform  capsule  in  the  aperture  of  the  de 
Trey  inhaler.  Say  nothing  about  the  breathing  in  the 
beginning-.  Place  the  inhaler  over  the  nose  and  mouth  ;. 
push  the  barrel  in  as  far  as  it  will  go.  Xow,  the  pa- 
tient is  getting,  as  nearly  as  I  can  estimate,  two-thirds 
air  and  one-third  somnoform.  After  two  or  three  in- 
halations, release  the  pressure  on  the  thumb  and  permiL 
the  barrel  to  close  the  aperture  about  one-third.  Allow 
the  patient  to  take  about  two  inhalations  and  permit 
the  barrel  to  assume  its  original  position,  in  which  case 
all  air  is  excluded.  One  or  two  inhalations  with  all  air 
excluded  is  usually  sufficient.  If  a  deeper  anaesthesia 
is  desired,  more  inhalations  can  be  taken  with  the  air 
excluded.  If  the  patient  breathes  normall}-,  do  not 
interrupt  her.  If  she  breathes  too  deeply  or  not  deeply 
enough,  then  in  a  quiet,  firm  voice  command  or  sug- 
gest the  degree  of  respiration  you  desire.  Ana?sthe3ia 
thus  induced  is  much  more  agreeable  to  the  patient, 
there  is  rarely  struggling  or  excitement,  nausea  seldom 
occurs,  and  supervening  headache  is  almost  unknown. 
Circulatory  disturbance  is  less  marked  than  when  all 
air  is  excluded,  and  it  is  certainly  much  safer  in  elderly 
people  with  brittle  arteries. 

Just  at  this  stage  Ave  will  assume  that  instead  of 
one  tooth  this  patient  has  half  a  dozen  teeth  to  be  re- 
moved. The  patient  has  had  but  one  or  two  inhala- 
tions,  we   will   sav.   \\\\.\\   all  air   excluded.     X'ow  hold 


206  General  Ancesthetics  in  Dentistry. 

your  ear  very  close  to  the  patient's  nose.  You  will 
hear,  by  the  time  two  or  three  more  inhalations  have 
been  taken,  a  little  low  purring  sound.  This  is  caused 
by  relaxation  of  the  soft  palate,  and  comes  with  a 
little  deeper  anaesthesia  than  is  usually  necessary  to 
relax  the  arm  muscles.  Let  me  add  here,  that,  when 
this  g:entle  snoring  sound  is  heard,  I  believe  the  pa- 
tient is  as  deeply  anaesthetized  as  is  necessary  for  any 
surgical  operation,  and  to  anaesthetize  longer  is  to  over- 
anaesthetize  the  patient  without  getting  a  more  pro- 
found anaesthesia. 

For  extracting  cases,  when  the  light  snoring  is 
heard,  remove  the  inhaler  and  begin  to  operate.  When 
other  operations  are  to  be  performed,  other  than  mouth 
operations,  at  this  stage  of  the  anaesthesia,  remove  the 
inhaler  for  an  inhalation  or  two  of  air,  then  replace  it, 
push  in  the  barrel  as  far  as  possible  and  proceed  as 
you  would  with  chloroform  or  ether;  if  sufficient  air 
is  not  admitted  in  this  way,  lift  the  inhaler  away  once 
in  a  while  and  replace  it.  In  this  way,  I  kept  a  patient 
under  the  influence  of  somnoform  for  twenty-five  min- 
utes. 

For  an  easy  extraction,  it  is  not  necessary  to  push 
the  anaesthetic  far  enough  for  snoring. 

Let  us  suppose  that  our  anaemic  patient,  after  tak- 
ing two  or  three  inhalations  of  somnoform  when  the 
barrel  is  being  tightly  held  and  the  patient  is  getting 
approximately  one-third  somnoform  and  two-thirds 
air,  should,  through  dread  or  apprehension,  become 
a  trifle  nervous  and  move  the  hands  and  feet,  I  would 
shut   off   nearly   or   quite  all   air  and  anaesthetize   the 


General  Amesthdics  in  Dentistry.  207 

patient  quickly.  This  seldom  happens,  but,  when  il 
does,  I  induce  a  quick  anaesthesia. 

Our  next  patient  is  a  plethoric  one  about  thirty 
years  of  age,  medium  height,  weighing  about  150 
pounds,  for  whom  it  is  necessary  to  extract  a  lower 
left  second  molar.  We  have  said  that  this  patient  is 
plethoric,  and  this  is  the  keynote  of  this  case.  We 
have  this  time  to  deal  with  a  red-faced,  full-blooded 
patient. 

We  have  already  shown  that  the  blood  flows  a  little 
more  rapidly  as  the  result  of  somnoform  adminis- 
tration, and  in  plethoric  people,  as  a  rule,  I  admit 
more  air  in  the  beginning  than  when  anaesthetizing 
anaemic  patients.  .If  all  air  is  excluded  from  the  very 
start,  these  patients  are  apt  to  become  excited.  I'he 
circulation  starts  up  too  rapidly  and  increased  circula- 
tion causes  a  feeling  of  fullness  in  the  head,  roaring 
and  unpleasant  noises  are  heard  and  we  have  a  con- 
dition more  like  that  produced  by  nitrous  oxid.  The 
patient  becomes  distressed  before  becoming  anaesthet- 
ized, and  the  dream  experienced  is  not  a  pleasant  one, 
as  a  rule,  if  the  air  is  insufficient  or  excluded  in  the 
beginning. 

The  mouth-prop  is  adjusted  and  the  patient  is 
ready  and  the  inhaler,  the  de  Trey,  is  in  position.  This 
inhaler  is  so  constructed  that  the  minimum  amount  of 
ansesthetic  inhaled  by  the  patient  when  the  barrel  is 
pushed  entirely  in  by  the  thumb  and  held  tightly 
against  the  face  is  about  thirty-three  per  cent.  For 
plethoric  patients  this  is  more  somnoform  than  I  desire 
them  to  inhale  in  the   bccinninc'.     T   do  not  want  the 


208  General  Afucsfhet'ies  rn   Dentistry. 

heart  to  start  up  too  suddenly,  because  it  frightens  the 
patient  and  makes  her  nervous  all  during  the  anaes- 
thesia. The  question  naturally  arises,  if  thirty-three 
per  cent,  is  too  much  somnoforni  to  admit  in  the  begin- 
ning and  it  is  impossible  to  exclude  less  than  this 
amount,  what  are  we  going  to  do  about  it?  I  have 
learned  to  overcome  this  difficulty  by  raising  the  lower 
part  of  the  hood  about  one-quarter  of  an  inch.  By 
the  hood  I  mean  the  inflated  soft  rubber  rim  that 
fits  over  the  celluloid  face-piece.  It  is  not  necessary 
to  lift  the  entire  face-piece.  Press  tightly  on  the  top, 
the  part  that  rests  over  the  nose,  and  raise  just  a  little 
the  part  that  covers  the  mouth.  Then  your  patient 
gets  a  volume  of  air  and  not  very  much  anaesthetic. 
Permit  one  or  two  inhalations  as  described,  then 
press  tightly  the  hood  al)out  the  face  and  gradually 
decrease  the  amount  of  air  and  increase  the  amount 
of  somnoform.  You  have  now  simply  to  watch  your 
patients  for  anaesthetic  symptoms  and  proceed  from 
now  on  just  as  with  the  aucvmic  patient.  These  plethoric 
patients  can  be  anaesthetized  just  as  quickly  as  anaemic 
patients,  but  I  always  take  a  little  more  time  with 
the  former  and  am  satisfied  lliat  1  am  well  re-paid  for 
using  a  little  slower  metbod. 

I  have  experienced  no  special  difficulties  with  the 
de  Trey  inhaler  and  liave  f(Muid  it  \-ery  satisfactory, 
indeed;  but.  since  my  attention  was  first  called  to  the 
Stark  inhaler.  I  have  used  it  almost  exclusively.  I 
tested  this  inhaler  for  more  than  a  year  before  men- 
tioning it  in  a  dental  journal  or  using  it  at  a  dental 
meeting.     I  described  il  in  llie  Dental  Brief  for  Decern- 


General  AjiasUictics   in   Doitistiv. 


209 


ber,  1907,  and  gave  a  talk  and  demonstration,  Decem- 
ber 4th,  '07,  before  the  junior  medical  class  and  the 
senior  andjjunior  dental  classes  of  the  Colleges  of  Medi- 
cine and  Dentistry,  State  University  of  Iowa,  angesthet- 


Stark  Somnoform  Inhaler,  for  Continuous  or  Repeated  Admin- 
istration of  Somnoform,  and  for  Ether  Sequence. 

izing-  a  dozen  students  selected  by  the  professor  of  ma- 
teria medica  of  such  temperaments  and  pathological 
conditions  as  he  wished  anaesthetized  for  the  benefit  of 
the  class.     Just  a  year  ])rcviously  1  anaesthetized  Pror. 


210  General  AtUEsthetics  in  Dentistry. 

Chase  and  three  of  his  medical  students,  with  the  de 
Trey  inhaler,  in  fifteen  minutes,  and  in  just  fifteen 
minutes  after  anassthetizing  Prof.  Chase  he  was  lectur- 
ing to  another  class. 

As  the  Stark  inhaler  has  already  been  described,  we 
will  now  explain  how  to  use  it. 

Let  us  select  this  time  a  nervous  little  black-haired, 
sallow  patient  given  to  hysteria,  one  that  insists  she 
knows  she  can  not  take  "the  stuff"  because  she  will  die. 
She  also  knows  that  it  will  nauseate  her,  and  that  she 
will  have  an  awful  dream,  etc.  These  patients  become 
very  nervous,  usually,  before  taking  the  first  inhala- 
tion, and,  if  the  first  inhalation  is  strong,  they  go  all 
to  pieces. 

This  patient  has  the  teeth  properly  held  apart,  the 
inhaler  is  in  position  and  the  patient  begins  to  iuliale. 
This  patient  does  not  get  thirty-three  per  cent,  of  som- 
noform  in  the  very  beginning.  That  amount  at  the 
start  would  almost  if  not  completely  defeat  ansestheli- 
zation. 

This  patient  is  watching  very  closely  and  will  re- 
bel at  the  slightest  provocation.  With  the  Stark  in- 
haler, you  can  have  her  breathe  for  five  minutes,  if 
you  wish,  and  the  patient  will  not  get  so  much  as  an 
unpleasant  odor.  All  this  time  you  can  be  suggesting 
that  the  anaesthetic  is  not  the  least  bit  disagreeable, 
that  the  odor  is  mild  and  pleasant,  and  when  you  are 
ready  you  can  admit  just  a  trace.  By  this  time,  the 
patient  is  calmed,  thinks  there  is  nothing  disagreeable 
about  it,  and,  by  gradually  admitting  a  little  more  at  a 
time,  it  steals  so  quietly  over  the  mucous  membrane 


General  Ancesthctics   in   Dentistry 


211 


into  the  lungs  that  the  patient  is  anaesthetized  before 
she  knows  it  without  a  struggle.     I  have  accomplished 

this    scores    of    times,    with    the    Stark    inhaler,    with 

+ 


StE    LARGER 
ILLUSTnATION    BELOW 

MK  or-Kvivr. 


INFLATABLE 


TFJ.KSCOPING 
CAP 

iAMBER 


SOMNOFORN  VALVE 

AlH    OPENINGS 

LEVER   COM  TROLLING 
BOTH 


iHAMEWORh 

ser\rates  to 
£mpty  broken 
Class  held  b\ 

OACZK 

i^VIRES    TO 
SVPPORT  LITNT 


SHOLLREH   ANO 
FLANGE 
SUPPORTING  BAG 


+ 

Detailed  Construction  of    Stark  Somnoform   Inluiler. 

patients  that  gave  every  evidence  of  a  most  unsatisfac- 
tory anaesthesia.  Yesterday  I  operated  for  a  little 
red-headed  girl  of  seven  years  of  age.     She  was  very 


212  General  A)ia-sihciics  in  Dentistry. 

brave  till  I  placed  the  mouth-prop  in  position,  then  she 
lost  all  control  of  herself  and  it  looked  like  a  defeat. 
I  placed  the  inhaler  over  her  mouth  and  she  held  her 
breath.  I  knew  she  could  not  hold  her  breath  forever, 
and  the  longer  she  held  it  the  deeper  would  be  the 
next  inhalation.  The  inhaler  was  over  her  mouth  and 
a  physician  and  her  father  held  her  hands.  AAMien  she 
started  to  exhale,  I  turned  on  about  ten  per  cent,  of 
somnoform  which  w^ent  into  her  lungs  with  that  first 
deep  inhalation.  The  same  amount  the  second  time; 
the  third  time,  I  only  admitted  about  half  as  much 
somnoform,  for  she  was  breathing  very  deeply.  One 
more  inhalation  of  about  five  per  cent,  of  somnoform 
was  all  she  needed,  and  I  made  a  successful  extraction 
of  a  sixth  year  molar  in  a  state  of  acute  alveolar  ab- 
scess too  badly  broken  down  to  save.  You  can  control 
the  amount  of  somnoform  desired  for  a  given  case  abso- 
lutely with  the  Stark  inhaler. 

I  could  have  held  the  inhaler  over  the  mouth  of 
this  patient  till  she  resumed  normal  breathing-,  had 
I  so  desired,  without  the  little  girl  inhaling  a  bit  of 
somnoform,  but  she  was  growing  more  nervous,  of 
course,  all  the  time  and  I  was  so  sure  of  my  appliance 
that  1  felt  no  alarin  whatever.  I  could  not  have  made 
this  fine  adjustment  with  any  other  appliance  with 
which  I  am  familiar. 

AVhen  speaking  of  nausea,  I  referred  to  a  young 
lady  v/hose  stomach  was  so  delicate  that  tlie  odor  of 
meat  being  broiled  or  fried  was  sufficient  to  nauseate 
her.  Her  mother  called  me  to  one  side  and  explained 
this  before  I  administered  the  anaesthetic,  thinking  she 


General  Anccsihetics  in  Dentistry. 


213 


might  become  sick  before  I  had  time  to  begin  the 
operation.  I  knew  this  young  lady  had  to  be  handled 
very  carefull}'  or  we  would  be  defeated  and  fail  to  make 
the  extraction.  I  was  as  careful  in  this  case  as  wiili 
"the  hysterical  patient  previously  described.  I  excluded 
somnoform  for  a  period  of  a  minute  or  two,  allowing 
only  air  to  pass  through  the  inhaler  till  I  had  the  pa- 


-^ 


s^i 


Box  Holding  Twelve  5  c.  c.  Capsules. 


tient's  confidence,  then  turned  on  just  a  trace  of  som- 
noform, and  continued  this  for  thirty  to  forty  seconds, 
then  just  a  little  more  for  nearly  as  long.  I  knew  ncv 
the  nerves  were  sufficiently  anaesthetized  not  to  take 
cognizance  of  the  odor  and  gave  her  two  inhalations 
without  air,  and  the  anaesthesia  induced  was  all  I 
needed.     1   made  a  successful  operation  and  no  nausea 


214  General  Ancesthetics  in  Dentistry. 

resulted.  I  ma}'  have  had  patients  as  sensitive  i6- 
odors  as  this  one,  but,  if  they  were,  it  was  not  so 
thoroughly  explained  to  me,  and  I  did  not  realize  the 
situation  as  in  this  case.  With  the  de  Trey  inhaler 
thirty-three  per  cent,  would  have  been  the  least  amount 
of  somnoform  that  I  could  have  accurately  admitted. 
For  a  less  amount  the  hood  must  have  been  lifted  and 
air  admitted  to  dilute  the  somnoform,  which  at  best 
is  only  guess  Avork. 


General  Arucsthehcs  in   Dentistry.  215 


LECTURE  XVIII. 

Somnoform  Administrations — Continued. 

I  have  learned  by  experience  that  patients  coming- 
from  the  farm  and  those  leading  out-door  lives  do 
not  stand  deprivation  of  oxygen  to  the  same  de- 
gree vi^ithout  discomfort  as  those  who  lead  a  more 
sedentary  life.  Clerks  in  stores,  book-keepers,  house- 
wives and  the  like,  whose  work  necessitates  long- 
hours  indoors,  can  be  anaesthetized  comfortably  with 
less  oxygen  than  those  that  spend  much  time  out 
of  doors.  I  think  that  this  statement  will  account 
for  some  of  the  cases  that  have  been  reported  to 
me  by  others  in  which  the  patient  became  excited 
and  made  a  disturbance.  Too  much  somnoform 
was  administered  in  the  very  beginning  and  not 
a  sufficient  amount  of  air.  The  circulation  and 
blood  pressure  being  suddenly  augmented,  the  pa- 
tient becomes  violently  stimulated  and  excited 
rather  than  anassthetized,  and  the  effect  is  nuich  the 
same  as  that  produced  by  ether  in  the  stimulation 
stage.  Many  patients  have  to  be  held  down  during  this 
stage  in  ether  administration,  and  many  more  would 
make  disturbances  in  hospital  practice  but  for  the  fact 
that  they  are  strapped  to  the  table  in  advance,  and 
ether  anaesthesias,  that  to  all  outward  appearances  are 


216  General  A)UCsUietics   ui   Dentistry. 

calm  and  without  a  struggle,  are  so  only  because  the 
patient  can  not  move. 

A\^e  have  this  same  condition  in  nitrous  oxid,  but  it 
occurs  much  more  frequently  than  in  somnoform.  We 
find  it  present  in  a  much  less  degree  in  chloroform  than 
in  ether.  We  have  less  of  it  in  somnoform  than  with 
any  other  anaesthetic  with  which  I  am  acquainted.  In 
all  stages  of  ancesthesia,  from  first  to  last,  we  may  say, 
nitrous  oxid  is  to  ether  what  somnoform  is  to  chloro- 
form. In  the  matter  of  excitability,  we  may  arrange 
them  in  the  following  order:  ether,  nitrous  oxid,  chloro- 
form,  ethyl  chloride  and  somnoform. 

In  my  own  practice,  I  have  never  had  a  case  in 
^^•hich  the  disturbance  has  been  of  sufficient  importance 
to  relate.  IVrhaps  this  is  so  from  the  fact  that  I  never 
attempt  to  restrain  a  patient.  There  is  a  stage  just 
before  consciousness  returns  when  patients  are  almost 
but  not  cjuite  awake,  in  which  the}^  are  greatly  mysti- 
fied and  thcv  do  not  know  where  they  are  or  what 
they  arc  doing  or  what  is  being  done  to  them.  This 
is  the  time  in  m}-  i)ractice  when  I  insist  on  everybody 
in  the  room  remaining  absolutely  quiet.  Do  not  shake 
the  patient,  or  tell  him  to  lean  forward  or  thrust  the 
cuspidor  under  his  chin  and  call  to  hiiu  to  spit.  Place 
napkins  in  the  moulli  as  ah"cady  explained  to  absorb 
the  l)loof!  and  allow  the  patient  to  awake  as  from 
natural  sleep.  If  his  dream  happens  to  be  an  unpleas- 
ani  om'  and  ]\l-  should  misinterpret  your  pushing  him 
forward  and  shaking  him  for  the  attack  of  the  villain 
he  sees  in  Ids  dream,  he  may  Feel  called  upon  to  defend 
himself  and    \on   lia\'e  a  figlil   on   \our  hands. 


General  Anceslhetics  in  Dcn/istry.  217 

The  following"  case  is  the  most  pronounced  of  its 
kind  that  has  ever  come  under  my  personal  observa- 
tion. The  patient  was  referred  for  the  extraction  of  a 
lower  right  third  molar.  As  soon  as  I  saw  him,  it 
occurred  to  me  that  this  man  would  make  trouble.  In 
size  he  was  about  five  feet  six  inches  in  height  and 
Avould  weigh  probably  two  hundred  pounds.  I  in- 
quired if  he  had  ever  taken  an  anjesthetic.  He  informed 
me  that  he  had  about  a  year  previously  at  the  hospital 
and  that  it  took  all  the  doctors  and  nurses  in  the  insti- 
tution to  hold  him.  He  ventured  the  opinion  that  the 
annssthetic  I  proposed  using  "could  not  put  him  to 
sleep."  We  made  him  ready  for  the  anaesthetic,  and 
I  motioned  the  assistant  to  stand  well  back,  lest  he 
should  strike  her  suddenly  and  without  warning,  with 
his  fist.  I  had  a  friend  knocked  stifl:  on  one  occasion 
b}^  just  such  a  patient,  when  administering  nitrous  oxid 
gas.  The  patient  inhaled  as  instructed,  and  I  thouglit 
him  almost  ready  for  the  operation,  I  lifted  his  hand 
to  test  his  muscles,  and  there  was  where  I  made  my 
mistake.  Two  inhalations  more  would  have  placed 
him  beyond  recognizing-  any  physical  disturbance.  I 
disturbed  his  consciousness,  and  he  said.  "Come  on, 
fellows;  let's  get  right  after  them."  He  was  on  his 
feet  in  a  moment.  grabl)ed  the  towel  from  his  neck, 
opened  the  door  into  the  reception  room,  put  on  his  hat, 
went  out  into  the  hall,  and  just  as  he  was  entering' 
the  reception  room  of  my  neighbor  consciousness  re- 
turned. I  walked  along  with  him,  telling  him  to  be  m 
no  hu'"rv,  "Just  wait  a  moment,"  but  not  restraining 
him    in    the   least.      We   walked   liack   too-ether,   he   in- 


218  General  Aiucsfhctics   i>i   Dcntislry. 

<jnired  if  I  removed  the  tooth  or  if  he  made  any  disturb- 
ance, put  on  his  hat  and  said :  "I  will  try  it  again  an- 
other day."  This  man  impressed  me  as  being  an  alco- 
holic. He  would  not  have  tolerated  restraint;  it  would 
have  been  a  mistake  to  have  tried  to  force  him  to  in- 
hale more  of  the  somnoform. 

All  other  cases  in  which  there  has  been  undue  ex- 
citement as  the  result  of  somnoform  administration, 
in  my  practice,  have  occurred,  after  the  induction  of  an- 
aesthesia and  after  the  patient  has  been  operated  upon. 

I  recall  a  case  of  this  kind.  At  the  close  of  the  an- 
.sesthesia,  the  patient  grabbed  his  right  side  pocket 
with  both  hands,  holding  it  tenaciously.  I  did  not  try 
to  interfere  Avith  him;  had  I  done  so,  I  probably  would 
have  been  roughly  handled.  In  the  course  of  a  few 
seconds,  he  realized  his  actions  and  laughed  heartily. 
I  said,  "What  kind  of  a  dream  did  you  have?"  He  re- 
plied, "I  have  $400.00  in  that  pocket,  and  I  thought 
some  one  was  tr3'ing  to  rob  me."  Had  I  undertaken 
to  hold  this  man  in  the  chair,  or  restrained  him,  he 
■would  have  resisted  violently. 

Another  case — A  large  man  over  six  feet  tall  and 
well  pro]Kjrtioned.  at  the  conclusion  of  an  extraction 
said.  "'Let  me  out  of  here."  I  stepped  aside  and  let 
him  lea\e  the  chair,  lie  picked  up  his  hat  and  walk- 
to  the  door  leading  from  the  private  room  to  the  hall. 
I'lnding  this  door  locked,  he  turned  and  just  then  re- 
gained consciousness  and  said,  "What  am  I  doing  here? 
Oh,  yes;  I  was  having  a  tooth  out.  Did  you  get  it?" 
This  man  was  a  pronounced  alcoholic.  His  jjliysicran 
accompanied   him   to  tlie  office,   fearing  a   disturbance, 


General  Ancesthetics  in  Dentistry.  219 

which  we  would  have  undoubtedly  had  if  an  attempt 
had  been  made  to  restrain  him. 

The  following  case  was  reported  to  me,  October 
15th,  1907,  by  Dr.  Z.  T.  Roberts,  of  Rocky  Ford,  Colo., 
with  permission  to  use  it: 

"A  farmer,  about  forty  years  of  age.  presented  for 
seven  extractions.  He  took  somnoform  nicely,  and 
I  took  out  all  the  teeth.  He  slept  on  for  probably  a 
minute  and  a  half,  when  he  suddenly  shouted,  "AVhoa!" 
at  the  top  of  his  voice  several  times,  and  tried  to  get 
out  of  the  chair.  I  pulled  him  back  into  the  chair  and 
held  him.,  whereupon  he  began  to  curse  me  and  strug- 
gled to  get  out.  Finally  he  broke  loose,  and,  raving  like 
a  mad  man,  faced  me.  At  this  time  his  reason  returned, 
probably  through  recognizing  me,  and  he  quieted  at 
once.  This  I  suppose,  was  merely  a  freak  of  anaesthesia, 
and  not  uncommon  with  any  anaesthetic ;  however,  it 
is  the  only  case  of  the  kind  I  have  ever  had,  and  I 
have  been  giving  it  about  two  years.  I  have  given  it, 
probably,  about  five  hundred  times." 

This  man  was  driving  his  horses  and  evidently 
did  not  wish  to  be  disturbed,  and,  had  the  Doctor  not 
tried  to  restrain  him,  he  probably  would  have  awakened 
in  a  pleasant  frame  of  mind. 

This  Rocky  Ford  case  reminds  me  of  the  delight- 
ful time  I  had  last  June  at  Colorado  Springs,  where  I 
attended  a  meeting  of  the  Colorado  State  Dental  So- 
ciety. During  my  talk  before  the  society,  I  had  men- 
tioned that  somnoform  is  non-irritating  to  the  mucous 
membrane  or  air-passages,  being,  for  that  reason,  a 
most  excellent  anaesthetic  in  all  broncheal  or  pulmon- 


220  General  Ancvsthetics  in  Den  fi  sir  v. 

ary  conditions.  At  ihe  close  of  my  remarks,  a  dentist 
came  to  me  and  told  me  that  he  was  a  great  sufferer 
from  asthma.  He  said  that  many  nights,  not  being* 
able  to  recline,  he  was  compelled  to  sit  in  a  chair  all 
night.  He  was  compelled  to  stay  in  a  high  altitude., 
then  being  a  resident  of  Victor,  Colo.,  which  has  an  al- 
titude of  more  than  10,000  feet.  He  had  listened  with 
great  interest  to  what  I  had  been  saying  and  request- 
ed me  to  anaesthetize  him  privately,  lest  through  nerv- 
ousness or  coughing  he  would  cause  me  to  make  a  fail- 
ure of  my  demonstration.  I  asked  him  if  this  was  his 
onlv  reason  for  desiring  a  private  anesthetization,  and 
he  assured  me  that  it  was.  I  told  him  not  to  hesitate 
for  a  moment,  that  he  would  have  the  most  comfort- 
able and  refreshing  sleep  that  he  had  experienced  in 
years.  I  placed  him  on  a  couch  and  in  about  forty-five 
seconds  he  was  sleeping  beautifully.  I  am  sure  those 
present  will  never  forget  his  many  expressions  of 
delight.  He  stated  time  and  again,  that  he  had  not 
experienced  such  a  sense  of  comfort  since  his  boyhood 
days. 

Dr.  B — ,  another  dentist,  informed  me  that  he  had 
remained  in  that  high  altitude  until  he  had  become  a 
nervous  wreck.  He  expressed  a  desire  to  be  anaes- 
thetized. (l(iul)ting  that  one  in  his  nervous  condition 
could  be  successfully  ana;sthetized  with  somnoform.  I 
assured  him  that  he  could  be  as  comfortably  anaesthet- 
ized as  the  gentleman  with  the  asthma.  The  predic- 
tion proved  to  be  true. 

.Some  months  since,  I  met  a  friend  on  the  street.. 
a    pliysician,    and    in    the    course    of    conversation    he 


General  Anaesthetics  in  Dentistry.  221 

told  me  that  his  wife  had  been  suffering  with  her  teeth, 
and  that  it  was  necessary  to  have  four  of  them  ex- 
tracted, but  on  account  of  her  impaired  physical  con- 
dition, the  operation  had  been  delayed  from  time  to 
time.  This  lady  is  one  of  the  most  delicate  women 
I  have  ever  known.  About  a  year  previously,  while 
undergoing  an  apendectomy,  she  experienced  an  anaes- 
thetic collapse  and  for  two  hours  remained  in  a  critical 
condition.  With  such  a  history,  her  husband  v/as 
apprehensive  as  to  the  outcome  of  an  anaesthesia  in- 
duced for  the  removal  of  these  teeth,  yet  agreed  with 
me  that  it  would  be  equally  hazardous  to  extract  the 
teeth  without  employing  an  anaesthetic.  I  explained 
to  him  the  physiological  action  of  somnoform,  and  we 
decided  to  operate  the  following  morning.  The  patient 
is  a  nervy  little  woman  and  arrived  at  the  appointed 
hour,  cheerful  and  bouyant  in  spirits,  and  I  knew  that, 
in  such  a  frame  of  mind,  she  could  be  successfully 
anaesthetized.  The  husband  had  worried  all  night,  and 
Avas  alarmed  lest  an  accident  might  occur.  I  sug-- 
gested  that,  at  a  signal  from  me,  he  should  place  his 
finger  on  the  radial  artery,  and  if  he  discovered  the 
slightest  indication  of  approaching  danger  to  nod  his 
head  and  I  would  discontinue  the  ansEsthetic.  I  did 
not  wish  the  patient  to  feel  that  we  were  in  the  lea^^t 
apprehensive  about  her  condition,  and  for  that  reason, 
did  not  signal  the  doctor  to  take  her  pulse  until  she  had 
inhaled  sufficient  somnoform  to  dull  her  sensibilities. 
I  lifted  my  eyes  every  second,  or  two,  from  the  patient 
to  her  husband,  but  he  gave  no  signal.  I  lifted  her 
liand.  it  dropped,  showing  muscular  relaxation.     I  re- 


222  General  Ancesihetics  in  Dentistry. 

moved  the  teeth,  the  patient  slept  quietly  for  about 
thirty  seconds,  a  smile  lit  up  her  countenance,  and 
developed  into  an  odd  little  laugh,  peculiar  to  her,  and 
in  five  minutes  she  was  out  of  the  office,  on  her  way 
home.  The  amount  of  somnoform  used  in  this  case, 
was  not  over  one  cubic  centimeter  with  an  abundant 
mixture  of  air.  It  is  a  very  easy  matter  to  overanaes- 
thetize  a  patient,  and  that  was  what  happened  in  the 
case  of  the  patient  under  consideration  on  a  previous 
occasion.  I  have  had  a  number  of  these  cases,  in  which 
the  family  physician  refused  to  administer  an  anaes- 
thetic on  account  of  an  impaired  physical  condition, 
that  have  taken  somnoform  as  successfully  as  the  wife 
of  my  friend,  the  physician. 

There  is  a  condition  of  analgesia  following  som- 
noform anaesthesia  that  is  valuable  to  the  dental  sur- 
geon. After  the  patient  is  perfectly  conscious  and  has 
freed  the  mouth  from  blood,  there  is  a  period  of  several 
seconds  in  which  considerable  can  be  done.  Some- 
times, in  rapid  extracting  where  a  number  of  teeth 
and  roots  are  to  be  removed,  the  blood  so  interferes 
with  vision  that  some  of  the  roots  are  overlooked, 
others  are  loosened  but  remain  in  their  sockets,  and 
sometimes  pieces  of  process  should  be  removed.  There 
are  some  patients  who  think  they  are  being  hurt  if 
they  know  something  is  being  done.  This  analgesic 
stage  is  of  no  practical  value  to  such  patients.  But 
there  are  other  patients  vx'lin  will  ])ermit  you  to  oper- 
ate if  they  do  not  feci  pain.  \\\\\\  this  class  you  can 
remove  such  roots  as  T  have  mentioned  and  they  will 
feel  no  pain  whatever. 


'  General  Amesthetics  in  Dentistry.  223 

Do  "not  misunderstand  me,  please.  I  believe  in 
operating,  primarily,  while  the  patient  is  unconscious 
and  to  cease  in  time  so  that  no  pain  shall  be  experi- 
enced. Be  sure  and  do  that.  If  there  is  any  little 
thing-  to  be  done  during'  this  analgesic  stage,  it  should 
be  done  with  the  full  consent  and  knowledge  of  the 
patient,  with  the  understanding  that  you  will  desist 
if  he  finds  he  is  being  hurt. 

I,  with  others,  have  recognized  this  analgesic  stage, 
but  I  did  not  appreciate  the  extent  to  which  it  might 
be  used  until  I  was  called  to  administer  somnoform  to 
an  elderly  lady  for  the  amputation  of  a  finger.  I  had 
used  a  3  c.  c.  capsule  of  somnoform  in  the  de  Trey  in- 
haler and  noticed  that  mv  patient  was  returning  to 
consciousness  and  I  asked  the  surgeon  if  I  should  use 
another  tube.  He  replied  that  it  would  not  be  neces- 
sary as  he  was  almost  through,  and  only  had  two  more 
stitches  to  take.  Just  then  the  patient  opened  her 
eyes  and  remarked,  "I  am  alive,  ain't  I,  doctor,  thank 
God."  I  assured  her  that  she  was  certainly  alive.  Then 
she  turned  to  the  surgeon  and  s?.".d,  "Whose  finger  is 
that  you  are  working  on?"  He  replied,  "Yours,"  "Oh, 
no,""  slic  said,  "That's  not  my  finger,"  and  she  pulled 
back  her  arm,  and  said,  "Why,  yes,  it  is ;  ain't  that 
funny !     You  are  not  hurting  me  one  bit." 

It  is  well  that  we  have  this  analgesic  stage  in  dental 
operations  for  the  following  reason  :  in  cases  of  acute 
alveolar  abscess  and  all  those  cases  in  which  consider- 
able force  is  exerted,  the  pain  does  not  discontinue  the 
moment  the  tooth  or  root  is  extracted,  and  the  after- 
pain  is  concealed  for  a  while,  or  until  it  subsides  in 


2i?4  General  Anasthetus  2>i  Dcn^^^'f'}'- 

a  large  measure,  or  completely.  With  nitrous  oxid, 
we  do  not  have  this  period  of  analgesia,  and  patients _ 
who  have  been  anaesthetized  frequently  insist  that  they 
have  been  severely  hurt,  and  felt  as  much  pain  as 
though  they  had  not  taken  the  gas.  I  believe  very 
many  times  it  is  this  post-operative  pain  that  is  felt 
under  nitrous  oxid,  and  not  the  actual  pain  of  operating. 

Yesterday,  a  dentist  brought  a  patient  to  me  to 
have  extracted  a  lower  left  third  molar  tooth.  This 
patient  also  had  an  upper  right  second  molar,  contain- 
ing a  dead  pulp,  that  was  so  sore  that  she  could  not 
stand  the  pressure  of  instruments  to  open  into  the  pulp 
chamber.  The  dentist  requested  me  to  open  the  pulp 
chamber  under  somnoform  after  removing  the  tooth. 
I  explained  to  the  patient  this  stage  of  analgesia,  and 
I  promised  her  that  she  should  not  be  hurt,  although 
she  would  probably  know  when  I  drilled  into  the  tooth. 
I  anaesthetized  the  patient  with  somnoform,  extracted 
the  third  molar,  removed  the  mouth-prop,  opened  into 
the  pulp  chamber  without  pain  or  annoyance  to  the 
patient. 

When  the  nervous  system  has  become  disordered 
by  the  use  of  tobacco,  chloral,  alcoholic  indulgence, 
morphine  or  other  narcotics,  patients  usually  exhibit 
abnormal  symptoms  during  or  after  anaesthetization. 
These  conditions,  no  doubt.  ex])laiu  abnormalities  and 
account  for  the  action  of  some  individuals  that  other- 
wise might  remain  a  mystery.  AJ()r])]iinc  is  often  in- 
jected short]}'  l)elore  adiiiiiiistcring  an  an;esthctic  to 
deepen  and  prolong  the  anaesthesia,  l)ut  those  addicted 
to  the  use  of  inorpliine  arc  suniclimcs  rcndcrc'(l  almost 


General  Anccsthetics  in  Dentistry.  225 

immune  to  an  anesthetic.  Dr.  R.  J.  Carter  furnished 
Hewitt,  of  London,  an  account  of  a  case  in  which  the 
patient,  a  morphiomaniac,  was  an  hour  and  three-quar- 
ters being  anaesthetized,  and  eight  ounces  of  chloro- 
form were  expended.  I  mention  this  as  a  matter  of 
interest,  as  it  may  serve  as  an  explanation,  should  you 
in  your  angesthetic  practice,  on  some  occasion,  fail  to 
produce  narcosis. 

Alcoholics  are  always  dreaded,  no  matter  what 
anfesthetic  agent  is  employed.  I  have  experienced  very 
little  difficulty^  however,  with  alcoholics  when  admin- 
istering somnoform.  I  have  had  a  number  of  narrow 
escapes  with  nitrous  oxid  and  became  suspicious  of 
any  person  that  smelled  of  liquor.  j\Iy  rule  with  ni- 
trous oxid  has  been  to  postpone  the  operation  if  I 
detected  the  odor  of  liquor  on  the  breath.  I  also 
adopted  this  rule  with  somnoform,  and  adhered  to  it 
strictly  for  two  years.  One  day  I  was  summoned  by 
'phone  to  administer  somnoform  for  a  finger  amputa- 
tion. When  I  arrived,  I  found  a  man  who  had  caught 
his  finger  in  a  sausage  machine  and  crushed  it  so 
badly  as  to  necessitate  amputation.  This  patient  had 
taken  several  drinks  of  whisky  and  Avas  partially  in- 
toxicated. I  did  not  know  how  successful  I  might  be 
with  somnoform,  but  there  was  nothing  else  to  do.  I 
decided  that  I  would  make  as  quick  an  anaesthesia  as 
possible,  and  give  him  no  time  in  which  to  become  ex- 
cited. I  had  him  snoring  in  thirty  seconds  and  he  never 
so  much  as  disturbed  a  muscle  of  his  body.  Thus 
deeply  anc4ssthetizcd,  I  admitted  two  inhalations  of 
pure  air,  and  after  that   I  permitted   him  to  take  one 


226  General  AncEsthetics  in  Dentistry. 

inhalation  from  the  inhaler  and  two  inhalations  of  air 
throughout  the  anaesthesia.  There  was  no  excitement, 
whatever,  either  during  or  after  the  anaesthesia.  This 
experience  excited  my  curiosity,  and  I  determined  that 
in  the  future  I  would  not  refuse  to  anaesthetize  a  patient 
because  of  the  fact  he  had  taken  a  drink.  Since  then 
I  have  refused  no  patient  on  that  account,  and  I  have 
had  no  occasion  to  regret  so  doing.  It  has  been  my 
privilege  to  anaesthetize  many  pronounced  alcoholics. 
I  recall  now  the  case  of  one  of  the  most  pronounced 
alcoholics  in  this  State.  This  man  was  referred  for  the 
extraction  of  an  upper  third  molar  on  the  right  side. 
I  admitted  an  abundance  of  air  along  with  the  somno- 
form  in  the  beginning  of  the  administration,  and,  as  it 
commenced  to  take  effect,  he  said,  "For  Christ's  sake, 
don't  begin  5'et,"  and  commenced  to  lean  forward.  I 
held  the  inhaler  over  his  face,  but  made  no  attempt  to 
restrain  him.  By  the  time  he  was  ready  for  the  opera- 
tion, his  head  was  far  enough  forward  to  rest  his  chin 
on  his  knees.  I  got  down  on  one  knee  and  did  the 
extracting.  All  this  time  he  was  repeating  the  sentence 
quoted  above,  and  said  it  ten  or  twelve  times  after  the 
tooth  had  been  removed.  In  about  a  minute  he  sat 
upright  in  the  chair,  expressed  himself  as  having  ex- 
perienced no  pain,  and  was  surprised  to  know  that  the 
tooth  was  out.  It  is_  said  to  be  difficult  and  sometimes 
impossible  to  secure  total  muscular  relaxation  in  alco- 
holic patients,  and  the  above  case  is  a  good  example 
of  this  condition.  His  muscles  were  contracted  from 
the  very  beginning  and  did  not  relax  at  any  stage  of 


General  Anccstheiics  in  Dentistry.  227 

the  anaesthesia.     He  was  neither  boisterous  or  noisy, 
and  made  no  physical  demonstration  whatever. 

About  a  month  ago,  two  ph3^sicians  brought  to  my 
office  a  third  physician  to  be  anaesthetized.  This  pa- 
tient, a  month  previously,  had  been  brutally  attacked 
by  some  ruffians  and  in  the  fracus  had  the  lower 
maxilla  fractured  on  both  sides  in  the  mental  foramen 
region.  Union  was  just  nicely  established  and  the 
bandages  and  splints  removed  and  it  was  found  that  the 
second  molar  on  the  right  side  had  moved  forward 
in  such  a  way  as  to  prevent  the  mouth  closing  and  we 
all  agreed  that  the  tooth  should  be  extracted.  •  This 
patient  had  been  under  the  influence  of  liquor  and 
morphine  for  a  month.  He  told  me  afterwards  that  he 
took  three  big  drinks  just  before  coming  to  the  office. 
When  I  commenced  to  anaesthetize  him  one  of  the  phy- 
sicians without  being  told  closed  in  on  his  knees  and 
braced  himself  in  front  of  the  patient.  The  other  phy- 
sician stood  on  the  left  side  and  grasped  the  wrist  of 
each  hand.  I  had  never  had  a  patient  held  like  this 
before,  but  there  was  no  time  to  argue  the  case,  so  I  said 
nothing.  The  tooth  extracted,  the  patient  was  a  little 
excited  and  warned  them  not  to  attempt  that  again  as 
he  had  his  gun  with  him  this  time  and  would  blow 
their  brains  out  if  they  did.  In  about  a  minute  he 
was  all  over  his  anaesthetic.  He  told  me  that  the  same 
crowd  was  after  him.  I  do  not  know,  of  course,  what 
kind  of  a  time  we  might  have  had  with  this  man 
alone.  The  physicians  told  me  afterwards  that  they 
knew  that  he  had  his  gun  in  his  hip  pocket  and  that 
was  why  they  came  over  with  him.  I  was  ver}'  glad 
that  thev  came,  because  I  went  through  a  nitrous  oxid 


22S  General  AncFsthetics  in  Dentistry. 

experience  on  a  former  occasion  when  an  alcoholic  had 
a  revolver  and  it  took  a  policeman  and  four  men  to  take 
it  from  him. 

After  that  experience,  as  long  as  I  remained  in 
the  South,  I  always,  for  a  man,  felt  his  hip  pocket  be- 
fore administering  gas.  Nearly  every  Southern  man 
in  those  days  carried  a  revolver. 

Indications  for  Operating  Under  Somnoform  Analgesia 
and  Anaesthesia. 

Recapitulation. — For  operations  on  the  teeth  other 
than  extracting,  when  a  condition  of  analgesia  is  de- 
sired, administer  somnoform  as  explained  till  the  pa- 
tient refuses  to  answer  questions,  or,  in  the  effort  to 
answer,  you  can  tell  by  the  hesitancy  or  slowness  of 
the  response  that  no  pain  is  being  felt.  As  long  as  the 
negative  reply  is  given  to  such  questions  as,  do  you 
feel  pain?"  "Am  I  hurting  you?"  "Do  you  mind 
what  I  am  doing?"  and  the  like  you  may  proceed 
.with  the  operation.  If  the  patient  gives  evidence  of 
feeling  pain  either  by  facial  expression,  or  verbally, 
administer  a  few  more  inhalations  and  continue  with 
the  work.  This  is  the  test  that  I  rely  upon  entirely  for 
•operating  during  the  analgesic  stage.  If  the  analgesic 
•stage  is  not  sufficient  for  the  operation  at  hand,  then 
the  patient  must  be  carried  to  the  anaesthetic  state. 

If  two  or  three  teeth  are  to  be  extracted  or  the  pulp 
•chamber  entered,  administer  somnoform  as  already 
■explained  and  watch  closely  for  anaesthetic  symptoms. 
If  you  follow  my  [)]an  and  liive  no  suggestion  what- 


General  Ancesihetics  in  Dentistry.  229 

ever  about  the  breathing,  you  will  observe  that  after 
two  or  three  inhalations  the  patient  will  begin  to 
breathe  a  little  slower  and  a  little  deeper.  This  is  an 
important  sign  of  approaching  anaesthesia.  There  will 
be  no  cyanosis,  no  discoloration,  the  patient  looking 
like  one  in  natural  sleep.  Have  the  patient  keep  the 
eyelids  closed.  At  this  stage  of  deeper  breathing,  press 
gently  on  the  closed  eyelids  over  the  eyeball.  If  the 
patient  does  not  flinch,  separate  the  lids  and  the  pupils 
will  usually  be  dilated.  Raise  the  arm  and  let  it  fall  in 
the  lap.  If  it  drops  without  resistance  the  patient  is 
surely  ready.  Even  if  the  arm  shows  some  resistance, 
\-ou  can  operate  painlessly  unless  you  undertake  to  do 
too  much  or  operate  too  long. 

If  the  operation  is  other  than  extracting  and  there 
is  no  blood  in  the  mouth  or  throat,  the  patient  can  be 
held  in  this  state  of  anaesthesia  by  alternate  inhalations 
of  air  and  somnoform  just  as  is  done  with  ether  and 
chloroform  ;  or  just  as  you  have  alread}"  been  instructed 
how  to  keep  the  patient  down  with  nitrous  oxid  and 
oxygen.  Use  air  with  somnoform  just  as  oxygen  is 
used  with  nitrous  oxid.  I  have  known  somnoform 
anaesthesia  to  be  maintained  in  this  way  for  a  period  of 
thirty-five  minutes  for  a  surgical  operation. 

If  the  stage  of  anaesthesia  described  is  not  sufti- 
ciently  deep  for  the  operation  at  hand,  continue  the 
antesthetic  till  a  light  snoring  sound  is  heard.  This 
snoring  indicates  that  you  may  now  begin  to  operate. 
Indeed,  I  do  not  believe  you  can  induce  a  more  pro- 
found anaesthesia  with  any  known  anaesthetic  than  we 
have  with   somnoform  at  the  snoring  stage.     To  ad- 


230  General  Ancesiheiics  in  Dentistry. 

minister  somnoform  longer  is  to  overansesthetize  your 
patient  without  inducing  a  deeper  anesthesia.  If  the 
operation  is  extraction  of  teeth,  you  may  now  begin. 
If  it  were  not  for  the  blood  accumulating  in  the  throat, 
after  removing  a  number  of  teeth,  if  the  patient  showed 
signs  of  feeling  pain,  a  few  more  inhalations  could  be 
given  and  the  patient  held  in  this  condition  long 
enough  for  any  dental  operation.  But  we  have  to  be 
careful  about  blood  collecting  in  the  pharynx  and 
larynx. 

For  operations  other  than  nose,  throat  and  mouth, 
at  the  snoring  stage  remove  the  inhaler,  allow 
a  breath  or  two  of  air  to  enter  the  lungs,  and  hold 
the  patient  at  this  degree  of  anaesthesia  or  a  little 
lighter  just  as  when  administering  chloroform.  You 
learn  when  the  patient  is  ready  for  the  operation  by 
repeatedly  administering  somnoform.  I  heard  Dr. 
Nevius  say,  at  the  recent  Chicago  College  of  Dental 
Surgery  Alumni  Clinic,  that  if  they  should  blindfold 
him  he  could  tell  by  the  breathing  when  the  patient 
was  anaesthetized,  under  nitrous  oxid,  and,  if  you 
stopped  his  ears  Avith  cotton  he  could  tell  by  the  ap- 
pearance of  Ihc  patient  when  to  operate.  I  rely  ii'pon 
the  general  appearance  and  condition  of  the  patient 
rather  than  any  one  symptom  or  sign. 

Dental  Uses  of  Somnoform. 

Somnoform  can  be  used  to  good  advantage  in  ail 
painful  conditions  which  the  dentist  is  called  upon  to 
treat.  There  arc  times  in  the  preparation  of  a  sensitive 
tooth  for  filling  vvlien  a  little  more  cutting  must  be 
done,  yet  the  patient  has  reached  his  limit  of  endurance. 


General  Aiucsiluiies  in  Dentistry.  231 

A  few  inhalations  of  somnoform  will  not  only  permit 
of  painless  cutting,  but  the  patient  will  be  rested  and 
refreshed  for  the  remainder  of  the  operation.  Some- 
times, in  preparing  a  tooth  for  a  crown,  just  at  the 
juncture  of  the  enamel  and  dentine  the  sensibility  '-S 
so  great  that  further  cutting  seems  impossible,  yet 
more  space  must  be  gained.  Three  or  four  inhalations 
of  somnoform  renders  the  patient  insensible  to  pain, 
A  patient  presents  with  a  case  of  acute  pericementitis 
the  result  of  placing  a  filling  in  too  close  proximity  to 
the  pulp.  The  tooth  is  so  sore  that  the  pressure  of  the 
tongue  against  it  causes  excruciating  pain.  Entrance 
to  the  pulp  must  be  made.  In  years  gone  by,  I  have 
spent  an  hour  or  more  getting  into  such  a  tooth.  By 
the  use  of  somnoform,  ivent  or  drainage  can  be  secured 
in  a  minute,  painlessly. 

A  child  has  walked  the  floor  all  night  long  crying 
because  of  a  case  of  acute  pulpitis.  She  comes  to  the 
office  next  morning  all  worn  out  from  loss  of  sleep  and 
hours  of  suffering,  added  to  which  is  the  dread  of 
being-  hurt.  Softened  dentine  must  be  removed  and  the 
pulp  exposed,  and  the  dentist  dreads  doing  this  almost 
as  much  as  the  patient  dreads  having  it  done.  Just  a 
little  somnoform  inhaled  will  enable  the  dentist  to 
make  an  exposure  and  seal  in  an  emolient  treatment 
before  the  little  one  opens  her  eyes  or  knows  that  the 
tooth  has  been  touched.  Exposing  pulps  for  arsenical 
applications  or  immediate  remo^•al,  or  removing  a  pulp 
after  an  arsenical  application  has  remained  the  requi- 
site time  for  those  patients  that  suffer  mentally  from 
anticipation  of  being  luirt  :  evacuating  pus  in  acute  al- 


232  General  Antcsihetics  in  Dentistry. 

veolar  abscess,  lancing  or  removing  a  portion  of  the 
gingival  tissue  in  nnerupted,  impacted,  or  belated  third 
molars.  Removing  cerumal  deposits  and  curetting  and 
cauterizing  deep  pus  pockets ;  opening  into  the  antrum, 
amputating  roots  of  teeth  in  cases  of  chronic  alveolar 
abscess,  operating  for  dentigerous  cysts,  alveolar  and 
maxillary  necrosis,  extraction  of  teeth,  and  other  opera- 
tions that  dental  surgeons  are  called  upon  to  perform, 
be  humane,  look  to  the  best  interests  of  your  patients 
and  yourself,  and  with  somnoform  or  some  other  anaes- 
thetic, do  all  these  operations  painlessly.  The  time  is 
coming  when  dental  surgeons  will  look  back  on  the 
present  cruel  and  barbarous  methods  of  operating  with 
pity  and  sorrow  in  their  hearts  just  as  the  general  sur- 
geon recalls  the  thousands  of  failures  he  made  in  the 
3'ears  that  have  Dassed  when  anaesthetics  were  not 
available. 

There  is  very  little  to  be  said  in  regard  to  adminis- 
tering somnoform  for  operations  on  the  teeth  other 
than  extracting.  When  you  have  learned  to  adminis- 
ter this  anaesthetic  successfully  for  extractions  there 
will  be  no  difficulty  in  getting  results  in  other  opera- 
tions. 

If  you  are  a  tyro  in  ana3sthetics  and  have  had  no 
jjractical  experience,  read  carefully  several  times  the 
lecture  on  Elements  of  Success,  before  attempting 
to  administer  either  nitrous  oxid  or  somnoform  for 
■other  operations  than  extracting. 

Indeed,  in  order  to  be  successful  in  this  line  of 
practice,  one  should  administer  somnoform  for  ex- 
traction cases  till  he  is  familiar  with  the  physiological 


General  Amcsihelics  in   Deniistvy.  233 

action  of  this  anaesthetic,  till  he  has  gained  confidence 
in  himself  and  is  master  of  the  situation. 

For  such  operations  as  we  are  now  considering  the 
Stark  inhaler  is  my  preference. 

To  simplify  matters,  let  us  assume  that  the  rubber 
dam  is  adjusted  and  a  cavity  of  decay  has  been  partially 
excavated.  The  tooth  is  now  quite  sensitive  and  the 
patient  becoming  nervous,  yet  considerable  cutting 
must  be  done  for  proper  cavity  preparation. 

■  Place  a  3  c.  c.  somnoform  capsule  in  its  compart- 
ment in  the  Stark  inhaler,  close  the  place  of  exit  in  the 
horizontal  cylinder,  fracture  the  capsule  by  pressing  on 
its  cover,  and  place  the  inhaler  in  position  just  as  you 
would  do  if  the  rubber  daiii  was  not  adjusted.  Say 
nothing  to  the  patient  about  the  breathing.  After  two 
or  three  inhalations  of  air,  turn  on  just  a  little  anaes- 
thetic, then  a  little  more,  and  address  the  patient  in 
such  a  way  as  to  require  an  answer.  The  patient  will 
have  a  feeling  of  drowsiness  creep  over  him.  You  can 
judge  from  the  "yes  or  no"  answers  as  to  the  state  of 
analgesia.  Just  as  consciousness  is  being  lost,  turn 
off  the  somnoform  and  hand  the  appliance  to  your  as- 
sistant. Begin  operating  now  gently  to  test  the  sensi- 
tivity of  the  tooth.  If  eas}-  cutting  can  be  accomplished 
without  a  protest  on  the  part  of  the  patient,  keep  on 
cutting,  saying  all  the  time,  "Am  I  hurting  you?"  "Do 
you  feel  pain?"  "Do  you  mind  it?"  etc.  Stop  any 
time  and  give  a  few  more  inhalations  and  continue  in 
this  manner  till  the  cavity  preparation  is  completed. 

In  the  case  of  lady  patients.  Avhen  you  make  your 
appointment  for  a  gi\cn  operation,  if  you  anticipate  us- 


234  General  Aineslhctics  in  Denfisfry. 

ing  either  somnoform  or  nitrous  oxid,  or  think  perhaps 
it  may  be  necessary  in  this  case  to  do  properly  what 
you  wish,  request  them  to  leave  off  the  corset  when 
dressing  for  the  office,  as  this  saves  complications  after 
the  patient  arrives.  You  always  get  a  more  comfort- 
able, a  safer  and  a  more  successful  anaesthesia  with  the 
corset  off,  and  do  not  run  the  same  risk  of  nausea. 
It  is  better  also,  when  convenient,  to  make  appoint- 
ments two  or  three  hours  after  a  meal,  or  have  the  pa- 
tient eat  lightly  or  not  at  all  if  the  appointment  comes 
just  after  the  breakfast  or  lunch  hour. 

If  a  patient  presents  with  a  severe  case  of  acute  al- 
veolar abscess,  the  result  of  a  dead  pulp,  with  a  tooth 
so  sore  that  it  seems  out  of  the  question  to  undergo,  the 
pain  of  entering  the  pulp  chamber,  insert  a  mouth- 
prop  and  without  adjusting  the  dam,  anaesthetize  the 
patient  just  as  you  would  for  the  extraction  of  teeth. 
With,  a  good  engine  and  a  sharp  bur  there  is  ample 
time  for  such  an  operation. 

If  the  operation  is  the  removal  of  a  live  pulp,  with 
the  dam  adjusted  and  a  prop  inserted  administer  som- 
noform as  you  would  for  an  extraction  case. 

If  you  wish  to  thoroughly  cauterize  pus  pockets  or 
curette  them,  have  all  instruments,  and  the  medicinal 
agent  to  be  used  in  readiness,  adjust  the  mouth-prop 
and  administer  somnoform  to  the  same  depth  of  anaes- 
thesia as  for  extracting. 

There  will  be  ample  time  to  bathe  the  tissues  with 
a  cocaine  solution  or  cocaine  ointment  to  prevent  or 
lessen  after-pain. 

One  such  thorough  treatment  under  an  anaesthetic 


General  Ancesthefics  in  Dentistry.  235 

does  more  good,  frequently,  than  weeks  of  treatment 
with  milder  agents. 

In  preparaing  sensitive  teeth  for  crowns  or  abut- 
ments, the  amount  of  cutting  necessary  will  suggest  the 
rnethod  to  be  emplo3^ed.  With  some  patients  the  grind- 
ing is  far  more  objectionable  and  more  wearing  and 
■exhausting  than  severe  pain  for  the  same  length  of 
time.  If  the  grinding  is  to  cover  several  minutes,  I 
would  adopt  the  same  method  as  described  for  cavity 
preparation,  without  adjusting  the  rubber  dam.  If 
just  a  little  cutting  was  necessary,  when  the  sensitive- 
ness became  too  severe  I  would  suggest  a  deeper  anaes- 
thesia and  complete  the  grinding  without  prolonging 
the  anaesthesia. 

It  is  not  necessary  for  me  to  dwell  upon  the  advan- 
tages of  operating  under  anesthesia.  It  is  apparent  to 
-every  one,  and  a  safe  method  by  which  this  could  be 
accomplished  has  long  been  looked  for  and  prayed  for, 
hot  only  by  the  dental  surgeon,  but  by  the  patient. 
Onlv  an  infinitesimal  number  remain  awav  from  the 
dentist  on  account  of  the  fee.  The  masses  postpone 
dental  operations  and  allow  their  teeth  to  fall  to  pieces 
in  their  mouths  because  of  the  torture  that  must  je 
submitted  to  in  having  them  operated  upon.  Cou'd 
some  man  invent  a  scheme  by  which  he  could  restore 
all  diseased  teeth  to  health  and  the  patient  had  but  to 
have  him  glance  into  his  mouth  when  instantaneously 
inlays,  fillings,  crowns  and  bridges  would  fly  into  posi- 
tion, the  check  book  would  be  produced  and  an}"  price 
named  would  be  cheerfully  paid. 


236  General  Amesthetics  in  Deniisir 


LECTURE  XIX. 

Chloroform  Analgesia. 

Dr.  Austin  C.  Hewett,  of  Chicago,  was  the  first  man 
to  advocate  the  performance  of  surgical  operations  in 
a  state  of  chloroform  analgesia.  He  was  one  of  the  first 
men,  if  not  the  first,  in  the  United  States  to  use  chloro- 
form. As  soon  as  the  news  reached  America  that  Sir- 
James  Y.  Simpson  had  used  chloroform  successfully.- 
Dr.  Hewett  imported  a  small  quantity  from  London  at 
a  fabulous  price  and  commenced  to  experiment.  At  the 
time  the  chloroform  arrived,  Dr.  Hewett  was  suffering 
with  an  abscessed  lower  molar.  He  took  a  few  inhala- 
tions of  chloroform  and  proceeded  to  evacuate  the  pus. 
He  pressed  a  lance  into  his  gum  without  any  sensation 
whatever.  Upon  removing  the  lance  he  was  amazed., 
for  the  stain  on  the  blade  indicated  that  it  had  passed 
a  quarter  of  an  inch  into  the  tissue.  He  then  took  a 
forceps,  and.  adjusting  it  to  his  tooth,  made  careful 
lateral  movements  without  pain.  Thus  encouraged,. 
he  extracted  his  own  tooth  without  the  least  discom- 
fort. Dr.  Hewett  was  at  this  time  a  medical  student 
and  for  years  after  graduating  had  a  large  medical  and 
surgical  practice  in  Southeastern  Michigan.  T'or  a  period 
of  more  than  twenty  years  he  performed  all  kinds  of 
medical  and  surgical  operations  in  a  stage  of  analgesia.. 


General  Ancesthehcs  in  Dentistry.  237 

notwithstanding"  all  the  authorities  in  this  country  and 
abroad  maintained  that  this  was  a  most  dangerous  pro- 
cedure. During  all  these  years,  had  a  death  occurred 
while  operating  in  this  stage  of  analgesia,  he  probably 
could  not  have  found  a  medical  man  in  all  the  world  to 
go  on  the  witness  stand  and  testify  in  his  favor.  "  After 
an  extensive  medical  and  surgical  practice  covering  a 
period  of  twenty-five  years,  realizing  the  great  neces- 
sity for  the  use  of  anaesthetics  in  dentistry,  he  aban- 
doned medicine  and  opened  a  dental  office  in  the  City 
of  Chicago,  quickly  establishing  a  large  and  lucrative 
practice  by  the  use  of  chloroform  for  all  operations  upon 
the  teeth.  Indeed,  he  refused  to  operate  in  painful 
conditions  unless  the   patient  inhaled  chloroform. 

.  In  May,  1893,  and  again  in  May,  1895,  Dr.  HeAvett 
read  papers  before  the  Iowa  State  Dental  Society  on 
chloroform  analgesia,  which  so  impressed  the  society 
that  a  committee  was  appointed  to  visit  Dr.  Hewett 
at  his  office  in  Chicago  and  make  a  report  of  what  he 
was  doing.  As  the  writer  was  the  chairman  of  that 
committee  and  wrote  the  report  which  was  printed  in 
the  proceedings  of  the  Iowa  State  Dental  Society,  for 
May,  1896,  he  takes  the  liberty  of  reproducing  portions 
of  that  report  in  these  lectures. 

"We,  the  undersigned,  a  committee  appointed  at  the 
last  annual  meeting  of  the  Iowa  State  Dental  Society 
to  visit  Chicago  and  investigate  the  Hewett  method  of 
anaesthesia,  beg  leave  to  submit  the  following  report: 
On  the  morning  of  July  17th,  1895,  at  9  A.  M.,  per 
agreement,  the  committee  met  at  the  Palmer  House 
and  proceeded  to  the  office  of  Dr.  A.  C.  Hewett,  No. 


238  General  Ancesihetics  in  Deniistry. 

491  AA>st  Adams  Street.  We  found  Dr.  Hewett,  his 
assistants  and  a  number  of  patients  awaiting  our  ar- 
rival. The  committee  had  placed  in  Dr.  Hewett's 
hands  a  month  or  more  in  advance  a  list  of  operations 
they  wished  to  have  him  perform,  covering  the  entire 
field  of  operative  dentistry.  When  we  arrived,  Dr. 
Hewett  extended  to  the  members  of  the  committee  the 
privilege  of  bringing  to  his  office  whom  they  wished, 
designating  the  operation  to  be  performed.  Further, 
the  members  of  the  committee  were  not  only  invited, 
but  urged  to  perform  the  operations  themselves,  he  ad- 
ministering the  chloroform  and  designating  when  to 
operate. 

"Case  I.     Operation — Preparation  of  Cavity  of  Decay. 

"Bessie  W — ,  age  eleven;  frail,  delicate  child,  poorly 
nourished;  ansemic.  Cavity  of  decay  in  lower  left  first, 
molar  grinding  surface.  Engine  was  used  till  the  tooih 
became  very  sensitive,  then  chloroform  was  adminis- 
tered— twenty  inhalations.  Time  of  preparation  of 
cavity,  two  minutes.  Child  reported  'no  pain'  after 
inhaling  the  chloroform.  Said  she  'would  not  dread  to 
come  again.'    Amalgam  was  used  for  the  filling. 

•"Case  II.     Operation — Extraction  of  Roots  of  Tooth. 

"Miss  McI — ,  age  about  thirty;  roots  of  lower  right 
first  molar  beneath  the  gum.  Used  modeling  com- 
pound for  an  impression;  impression  enlarged  a  little. 
In  this  was  placed,  along  the  sides,  cotton,  saturated 
with  Tlcwett's  compound  cocaine  pigment.'  The  parts 
were  thoroughly  dried,  the  four  per  cent,  cocaine  solu- 
tion applied  to  remove  mucus  and  foreign  substances; 


General  Anuesthetics  in  Dentistry.  239 

the  modeling  compound  slipped  back  in  position  and 
the  patient  instructed  to  bring  the  teeth  together. 
Now  the  patient  was  ready  for  the  chloroform  and  took 
sixteen  inhalations ;  roots  were  removed.  On  being 
questioned,  patient  said,  'No  hurt,  nothing,  not  the 
slightest  pain,  but  knew  when  I  opened  my  mouth  and 
when  the  instrument  was  applied.'  No  unpleasant 
SAanptoms. 

"Case  III.    Operation — Amputation  of  Pulp. 

"Miss  McI — ,  age  about  twenty-seven  ;  dried  gums 
and  used  compound  cocaine  pigment  prior  to  adjusting 
the  rubber  dam. 

"Tooth,  upper  right  bicuspid;  surface  involved, 
mesial.  Broke  down  the  enamel  walls  with  a  chisel  be- 
fore administering  chloroform.  Patient  never  had 
taken  chloroform  before.  Eighteen  inhalations.  She 
seemed  to  be  suffering,  judging  from  the  facial  ex- 
pression. The  coronal  portion  of  the  pulp  was  entirely 
removed  by  a  fast-rotating  bur.  Pulp  bled  profusely ; 
dressed  with  eucalyptol.  After  the  hemorrhage  ceased, 
a  pellet  of  tin  foil  was  burnished  over  the  remaining 
portions  of  the  pulp  and  cavity  filled  with  cement. 
Operation  to  be  completed  at  another  sitting.  Patient 
reported  'no  pain,'  but  knew  what  was  going  on. 
AVhen  asked  if  she  had  been  instructed  not  to  eat  be- 
fore coming,  replied  that  nothing  had  been  said  to  her 
about  that;  she  had  eaten  breakfast  as  usual  and  a 
hearty  lunch.  On  being  further  questioned,  said,  T 
would  not  dread  to  have  the  same  operation  performed 
on  another  tooth.' 


240  General  AncBsthetics  in  Dentistry. 

"Case  IV.      Operation — Ex:traction  of  Roots  of  Tooth. 

"Miss  ,   age   thirty-five ;   roots   of   lower   right 

second  molar  beneath  the  gum.  Took  impression  with 
modeling  compound ;  dried  the  parts ;  removed  mucus 
with  four  per  cent,  cocaine  solution,  then  replaced  the 
impression  containing  cotton  saturated  with  compound 
cocaine  pigment,  allowing  to  remain  about  a  minute 
before  and  during  inhalation  of  chloroform;  thirty-two 
inhalations.  This  was  a  difficult  case,  the  tissues  sur- 
rounding being  highly  inflamed  and  sensitive.  Patient 
reported  no  pain.  Said  she  had  been  trying  for  two 
years  to  get  the  courage  to  have  the  roots  removed. 
Never  took  chloroform  before ;  no  nausea,  no  unpleas- 
ant after  symptoms,  although  she  had  eaten  a  hearty 
lunch  just  before  leaving  home. 

"Case  V.     Operation — Shaping  Tooth  for  Gold  Crown. 

Mrs.  W — ,  age  forty-five  ;  lower  right  second  molar ; 
patient  a  delicate,  frail  woman.  Applied  four  per  cent, 
cocaine  solution  to  the  gum;  ground  tooth  with  corun- 
dum-wheels till  it  became  sensitive  at  all  points;  in- 
deed, very  painful.  Chloroform  was  now  administered, 
six  inhalations,  and  grinding  continued  until  patient  in- 
dicated it  was  painful,  then  eight  more  inhalations  of 
chloroform,  and  the  operation  was  completed.  Tooth 
was  cauterized  with  weak  silver  solution  of  silver 
nitrate,  and  patient  dismissed.  Time,  about  five  min- 
utes ;  tooth  having  small  neck  and  large  crown,  bell  ■ 
shaped,  considerable  cutting  was  necessary. 

"Case  VII.     Operation — Amputation  of  Pulp. 

"Mr.    M — ,    age    thirty-seven.      Upper    left    cus- 


General  Ancesthetics  in  Dentistry.  241 

pid,  mesial  surface.  Four  per  cent,  solution  of  cocaine 
applied  to  the  gum,  rubber  dam  adjusted  and  chloro- 
form administered.  Pulp  chamber  entered  with  rapid- 
ly rotated  bur.  Pulp  bled  profusely,  eucalyptol  used 
as  a  dressing;  tin  foil  burnished  over  the  remaining 
pulp,  and  cavity  filled  with  cement.  Patient  felt  some 
pain ;  no  nausea,  headache  or  uncomfortable  symp- 
toms from  the  chloroform. 

"Case  VIII.    Operation — Extraction  and  Replantation. 

"Miss ,  age  twenty-five.  Superior  right  cen- 
tral incisor  elongated  a  quarter  of  an  inch  beyond  the 
cutting  edge  on  the  adjoining  tooth.  Impression  tak- 
en and  cocaine  applied  as  in  former  extractions,  and 
held  in  place  while  taking  twenty-six  inhalations  of 
chloroform.  Pulse,  before  taking  the  anaesthetic,  120 
per  minute,  at  time  of  extraction,  100.  Tooth  ex- 
tracted and  bathed  in  eucalyptol,  apical  foramen  en- 
larged and  pulp  removed;  pulp  chamber  and  canals 
filled  with  chloro-percha.  Socket  deepened  with  bur, 
tooth  placed  in  position  and  driven  up  with  a  hammer, 
bringing  the  cutting  edge  on  a  line  with  the  left  cen- 
tral. A  splint  was  constructed  and  applied  and  the  pa- 
tient dismissed  till  the  following  day.  Time  consumed 
from  beginning  to  close  of  the  operation,  twelve  min- 
utes;   no  pain. 

"Case  IX.    Operation — Preparing  Tooth  for  Filling. 

"Prof.  C — ,  age  thirty-six.  Upper  right  first 
molar,  mesial  and  occlusal  surfaces.  Applied  com- 
pound cocaine  pigment  to  the  gum  and  adjusted  rub- 


242  General  AncestheHcs  in  Dentistry. 

ber  dam ;  used  engine  till  cutting  was  very  painful ; 
then  administered  chloroform,  twelve  inhalations.  The 
Professor  expressed  himself  pleased  with  the  results, 
as  the  cavity  was  ready  for  filling  in  about  three 
minutes." 

"Dr.  Hewett's  Attitude  in  Relation  to  Chloroform. 

"  'To  more  fully  define  my  attitude  in  relation  to 
chloroform  as  an  obtundent,'  says  Dr.  Hewett,  T  wish 
to  say  that  in  all  the  range  of  operative  dentistry,  and 
in  the  demands  of  oral  surgery,  there  are  but  four 
to  six  operations  demanding  or  justifying  its  exhibi- 
tion to  complete  anaesthesia.  The  obtundent  influence 
is  ample.  Under  no  circumstances  is  a  dentist  justi- 
fied in  fully  anaesthetizing  a  patient  for  extraction  of 
teeth  or  for  minor  operations  of  oral  surgery.  Dur- 
ing a  somewhat  lengthened  practice  never  an  accident 
or  an  approach  to  an  accident  has  occurred.' 

"As  a  result  of  careful  study  and  extensive  use,  Dr. 
Hewett  does  not  hesitate  to  commend  its  general  use 
as  an  obtundent.  (Please  observe  the  emphasis  on 
that  word.)  When  given  as  Dr.  Hewett  describes,  'it 
is  safe  for  the  3''0ung  and  aged,  the  robust  and  feeble, 
the  sick  and  the  healthy,  the  nervous  and  the  stolid. 
Thus  used  as  an  alleviator  of  pain,  chloroform  has  no 
known  rival.  A  substance  in  the  hands  of  the  unskilled 
and  reckless,  as  dangerous  to  human  life  as  prussic 
acid  or  dynamite,  but  used  properly,  legitimately,  as 
safe  as  the  odor  from  the  heart  of  a  rose.' 

"How  Administered. — 'Having  tested  numberless  de- 
vices, from  a  sponge  to  an  elaborate  machine,  I   (Dr. 


General  Ancesiheftcs  in  Dentistry.  243 

Hewett)  have  chosen  a  means  so  simple  as  to  be  ahiiost 
ridiculous.  ,\  wide-mouth ecU  half-ounce  to  ounce  bot- 
tle, an  ordinary  morphine  bottle,  is  as  good  as  any. 
Any  glass  bottle  two  and  one-half  inches  high,  an  inch 
and  one-half  in  diameter,  with  mouth  three-quarters 
of  an  inch  across,  will  do.  Of  course,  it  should 
be  clean.  If  the  chloroform  is  to  be  kept  in  the 
bottle  after  administration,  the  cork  or  stopper  should 
seal  hermetically,  and  the  bottle  wrapped  in  dark  paper 
and  kept  in  a  dark  place.  The  chloroform  should  be 
pure,  never  of  a  doubtful  manufacture.  Xo  preparation 
of  the  patient  is  necessary,  except  that  an  empty  stom- 
ach is  to  be  preferred.  Or  if  the  drug  is  to  be  given 
soon  after  a  meal,  the  food  should  be  light  in  quality 
and  quantity;  otherwise,  if  the  obtundent  effect  is 
pushed  to  or  near  the  anaesthetic  line,  slight  nausea 
may  supervene — the  only  ill  effect  Dr.  Hewett  has 
observed,  even  with  the  stomach  overloaded.  'Place 
not  to  exceed  a  teaspoonful  of  chloroform  in  the  bottle. 
With  the  bottle  open,  place  it  near  one  nostril  of  the 
patient  nearly  on  a  level  with  the  nose,  remembering 
that  the  vapor  of  chloroform  is  heavier  than  the  atmos- 
phere, and  the  narcoti.ved  air  tends  to  fall.  Compress 
the  opposite  nostril,  and  direct  the  patient  to  take  long, 
steady  inhalations  across  the  bottle's  mouth.  Do  not 
tolerate  spasmodic  or  jerky  breathing.  A\'hen  an  in- 
halation has  occurred,  remove  the  bottle  so  that  nothing" 
exhaled  shall  enter  to  contaminate  the  chloroform.  At 
first  the  bottle  should  be  distant  enough  for  only  the 
faintest  odor  to  be  detected;  at  no  time  near  enough 
to  irritate  the  fibrillar  of  nerves   spread  out  upon  the 


2-14  General  Anoesthetics  in  Dentistry. 

Schneiderian  membrane,  the  throat  and  lungs.  Do 
not  give  the  peripheral  nerves  a  shock.  The  medulla 
oblongata  lies  closely  contiguous,  and  will  respond  to 
the  irritation  all  too  readily.  Remember  that  the  nerves 
of  the  mouth,  nose,  throat  and  lungs  in  their  ultimate 
distribution,  if  on  a  plane,  cover  a  space  of  tAvelve  to 
fourteen  hundred  feet,  all  readily  accessible  to  the  nar- 
cotic-laden air.  Nerve  impulse  largely  controls  the 
sanguineous  circulation.  The  blood  absorbs  the  drug, 
and  its  globules  roll  over  each  other  to  the  heart,  to 
be  sent  out  to  the  brain,  viscera  and  ganglia  again. 

" 'Avoid  shock,  the  first  more  common  cause  of 
death  from  chloroform.  Allow  the  chloroform  to  steal 
over  the  peripheral  sentinels  so  gradually,  so  warily, 
that  it  shall  not  fire  an  alarm  to  the  trigemina  and 
medulla.  As  the  long,  regular  breathing  goes  on,  the 
bottle  can  be  placed  nearer  the  nose  till  stronger  vapor 
is  taken.  Presently  the  eyelids  will  begin  to  droop  or 
"wink"  lazily,  the  muscles  somewhat  relax,  and  an 
obtundure — to  coin  a  word — creeps  over  the  nerves.' 

'Tn  such  a  state  Dr.  Hewett  extracted  his  own  tooth, 
and  in  such  a  state  operates  for  his  patients.  In  this 
condition  the  drill  or  bur  can  be  carried  to  the  live  pulp 
and  the  pulp  amputated,  and  afterwards  the  patient 
will  say,  'I  knew  what  you  were  doing,  but  it  did  not 
hurt.'  In  the  case  of  children,  they  will  sometimes 
moan  and  cry  out,  but  after  restoration  express  no  re- 
sentment, and  all  dread  of  subsequent  operations  is 
dispelled.  From  what  they  saw  and  learned  in  Dr. 
Hewitt's  office,  the  committee  makes  the  following 
observations: 


General  Ancesihetics  in  Dentisiry.  245 

"Ihat  Dr.  Austin  C.  Hewett,  in  his  method  of 
administering-  chloroform  for  surgical  operations,  is  at 
variance  with  all  known  authorities  in  that 

"First.  His  patients  are  not  placed  in  the  recum- 
bent position. 

"Second.     That    he    operates    in    the    first    stage . 
when  an  obtundent  effect  is  produced  rather  than  the 
stage  of  complete  anaesthesia,  and  denies  that  shock 
is  ever  produced,  when  chloroform  is  administered  as 
he  directs,  from  operating  in  the  'obtundure'  stage. 

"Third.  That  in  thirty  years'  experience  in  his 
method  of  administering  chloroform  for  dental  and 
minor  surgical  operations  no  dangerous  symptoms 
have  ever  been  observed. 

"Fourth.  That  pain  can  be  reduced  to  a  minimum, 
or  be  entirely  overcome,  and  operations  on  the  teeth, 
other  than  extracting,  can  be  performed  in  a  third  to 
a  quarter  of  the  time  ordinarily  required. 

"Fifth.  That  an  operator  can  do  from  a  third  to 
a  half  more  work  at  the  chair  each  day  by  using  chloro- 
form, and  save  fifty  per  cent,  of  nerve  force  that  ordin- 
arily is  expended  in  quieting  and  encouraging  patients. 

"Further,  that  we  were  gratified  at  the  results 
produced. 

"Daily  we  are  amputating  nerves,  disemboweling 
them,  causing  groans  and  entreaties,  tears,  shock  often 
to  syncope,  sometimes  collapse.  We  believe  that  it 
is  as  incumbent  on  dentists  to  perform  operations  pain- 
lessly as  on  physicians,  and  that  Dr.  A.  C.  Hewett  has 
made  this  possible ;  that  the  average  painstaking,  in- 


246  General  AncBsihetics  in  Dentistry. 

telligent  practitioner,  with  proper  instruction,  can  learn 
to  use  this  method  advantageously. 

"  'It  was  from  the  discovery  of  Sir  Humphry 
Davy  that  the  inhalations  of  nitrous  oxid  gas  would 
relieve  the  pain  of  cutting  a  wisdom-tooth  that  the  first 
notion  of  inducing  anffisthesia  by  inhaled  vapors  took 
its  rise.  It  was  for  the  extraction  of  a  tooth  that 
Horace  Wells  gave  to  the  notion  its  first  practical  em- 
bodiment. For  a  similar  operation,  Morton  succeeded 
in  inducing  insensibility  by  means  of  ether.  The  first 
operation  performed  under  the  influence  of  ether  was 
the  extraction  of  a  tooth.'  Who  has  a  better  right  than 
the  dental  surgeon  to  use  anaesthetics? 

"We  believe  that  a  chair  of  ansesthesia  should  be 
established  in  every  dental  school,  in  order  that  anaes- 
thesia, both  local  and  general,  may  be  scientifically 
studied  and  taught.  That  the  resolution  on  the  records 
of  this  society  opposing  the  use  of  chloroform  in  den- 
tal practice  should  be  declared  null  and  void.  That 
the  dental  profession  at  large,  as  well  as  this  society, 
owes  a  debt  of  gratitude  and  a  vote  of  thanks  to  Dr. 
A.  C.  Hewett  for  making  public  his  discovery.  That 
the  Iowa  State  Dental  Society  is  indebted  to  Dr. 
Hewett  for  papers  and  addresses  on  this  subject  on  pre- 
vious occasions,  and  especially  for  the  hearty,  hospit- 
able manner  in  wliich  he  received  the  committee  which 
you  sent  to  Chicago  to  make  the  investigation  set  forth 
in  this  report. 

"Signed     W.  H.  De  Ford, 
"Geo.  W.  Miller, 
"I..  K.   Fullerton." 


General  Ancesihetics  in  Dentistry.  247 

I  soon  learned  to  operate  successfully  under 
chloroform  analgesia,  selecting-  at  first  the  more  favor- 
able cases  and  later,  after  gaining  confidence,  using  it 
whenever  desired.  It  is  not  my  purpose  to  burden  you 
with  the  citation  of  many  cases,  but  will  relate  two 
characteristic  of  hundreds  that  might  be  related. 

Mrs.  N —  came  to  me  to  have  removed  the  roots 
of  a  lower  left  third  molar  that  had  been  left  by  an- 
other operator.  Three  weeks  previously,  this  tooth  had 
been  fractured  in  an  attempt  to  remove  it  and  Mrs. 
N —  had  been  confined  to  her  home  ever  since.  An 
appointment  Avas  made  to  operate  the  next  day  at 
the  ofifice  of  her  physician  promptly  at  twelve  o'clock. 
This  physician  and  his  partner  had  administered  anes- 
thetics for  me  for  several  years  and  they  were  both 
most  excellent  ansesthetists.  The  patient  proved  to 
be  very  antagonistic  and  it  Avas  two  hours  before  we 
succeeded  in  angesthetizing  her  sufficiently  for  the 
operation  and  four  hours  more  before  the  patient  could 
be  removed  to  her  home.  About  six  months  later,  the 
same  patient  presented  complaining  of  the  lower  third 
molar  on  the  right  side.  I  refused  to  operate  for  this 
case  unless  she  would  take  chloroform  my  way.  We 
tried  both  ether  and  chloroform  for  the  previous  opera- 
tion and  she  fought  like  a  tiger  and  tired  us  all  out  and 
I  did  not  care  to  repeat  that  experience.  I  explained 
the  Hewett  method  and  made  an  appointment.  She 
kept  the  appointment  promptly,  but  could  not  muster 
up  enough  courage  for  the  operation.  Three  times 
she  backed  out  after  coming  to  the  office.  The  fourth 
time  she  was  accompanied  by  her  mother  and  we  were 


248  General  Ancesthetics  in  Dentistry. 

successful.  In  less  than  five  minutes  she  was  putting 
on  her  hat  unassisted,  only  a  few  administrations  being 
necessary,  and  there  was  no  pain  whatever,  and  this  the 
same  patient  that  required  two  hours  to  anaesthetize 
previously. 

The  second  case  is  that  of  a  very  stout  patient  al- 
most as  broad  as  she  was  tall,  weighing  about  two 
hundred  pounds,  a  patient  in  which  chloroform  ordin- 
arily would  be  counter-indicated.  She  remarked,  "I 
have  four  teeth  to  be  extracted  and  I  knew  that  you 
would  not  give  me  chloroform  so  I  brought  it  with 

me  and  this  is  Miss  ■ ,  a  trained  nurse,  and  she 

will  administer  it."  I  placed  her  in  the  chair  and 
explained  to  her  that  she  must  take  chloroform  my  way 
or  not  at  all.  I  poured  about  three  drams  of  chloroform 
from  a  new  pound  bottle  into  an  empty  morphine  bottle 
covered  with  blue  paper — the  one  presented  to  me  by 
Dr.  Hewett  himself,  the  one  he  used  in  the  presence 
of  the  Iowa  Committee.  The  patient,  seeing  this, 
laughed  heartily,  saying  that  it  would  take  all  that 
was  in  the  larg-e  bottle  to  put  her  to  sleep.  I  held  the 
bottle  at  some  distance  and  gradually  brought  it  closer 
and  closer  to  her  nose  and  she  took  about  twenty  in- 
halations, and  I  extracted  the  four  teeth,  without  the 
slightest  pain.  As  she  leaned  forward  to  free  her  mouth 
of  blood,  she  remarked,  "Why  don't  the  doctors  give 
it  this  way?"  Then  she  added,  "I  have  taken  anaes- 
thetics twelve  times  for  various  surgical  operations,  but 
if  I  ever  have  to  take  it  again,  even  if  I  am  in  New 
York  Citv,  I  am  going  to  send  for  you  and  have  you 
give  it  your  way." 


General  AncBsthetics  in  Dentistry.  249 


LECTURE  XX. 

Ether  and  Chloroform. 

I  shall  not  devote  very  much  time  or  space  to  ether 
and  chloroform,  because,  in  my  opinion,  these  agents 
should  not  be  used  by  the  dental  surgeon  to  induce 
surgical  anassthesia.  The  dental  surgeon  is  fortunate 
who  refuses  absolutely  to  allow  these  anaesthetic  agents 
to  be  administered  in  his  office.  A  busy  practitioner 
can  not  or  should  not  be  annoyed  and  delayed  and  dis- 
arranged by  turning  his  operating-room  for  the  time 
being  into  a  hospital.  Of  course,  a  dental  surgeon 
should  not  administer  ether  or  chloroform  under  any 
circumstances  without  the  aid  and  presence  of  a  medi- 
cal practitioner.  A  physician,  only  in  the  extremest 
emergency,  would  be  justified  in  administering  ether 
or  chloroform  without  the  presence  of  another  phy- 
sician. 

We  have  at  our  command  three  very  excellent  anaes- 
thetics, nitrous  oxide,  ethyl  chloride  and  somnoform. 
These  anaesthetics  may  very  appropriately  be  desig- 
nated office  anaesthetics  in  contra-distinction  to  ether 
and  chloroform,  which  may  properly  be  referred  to  as 
hospital  anaesthetics. 

The   line   must   be    drawn    somewhere,    and,    in    my 
opinion,  it  should  be  drawn  just  here.     Let  the  dental 


250  General  Ancesthetics  in  Dentistry. 

practitioner  confine  himself  to  the  angssthetics  which 
I  have  designated  office  aneesthetics,  and  turn  over  to 
the  physician  all  cases  in  which  ether  and  chloroform 
are  necessary. 

This  is  the  rule  by  which  I  work  in  my  anaesthetic 
practice.  All  cases  in  which  I  am  satisfied  the  office 
anaesthetics  are  not  indicated  go  to  the  hospital. 

If  the  patient  is  so  situated  that  the  hospital  is  o'c^ 
of  the  ouestion,  then  the  next  best  place  is  the  office 
of  the  physician  who  is  to  administer  the  anaesthetic. 
He  will  in  all  probability  have  a  good  surgical  table, 
good  light,  and  the  conveniences  that  go  hand  in  hand 
with  anaesthetic  administration,  and  a  good  assistant  or 
a  nurse  to  care  for  the  patient  after  the  operation. 
Probal^Iy  in  thirty  minutes  you  can  return  to  your 
office  ready  for  business. 

Should  the  anassthetic  be  administered  in  your  office, 
patients  will  be  dropping  in  at  an  inopportune  time. 
The  struggling  and  excitement  incident  to  the  anaes- 
thetic makes  it  embarrassing  for  those  waiting  and  on 
such  occasions  patients  are  always  numerous.  Vomit- 
ing and  sickness  nearly  always  follow  ether  and  chloro- 
form anaesthesia,  which  is  disgusting  and  nauseating 
to  those  waiting  their  turn.  You  can't  hurry  the  pa- 
tient out  of  the  office,  and  two  or  three  hours  of 
valuable  time  are  consumed  as  against  a  few  minutes 
when  the  anaesthetic  is  administered  outside  of  the 
office. 

If  the  physician  will  not  permit  the  use  of  his 
office,  then  arrange  to  go  to  the  home  of  the  patient. 
There  are  many  objections  to  this,  I  know,  in  the  way 


General  Ancesihetics  in  Dentistry.  251 

of  a  poor  light,  the  back-breaking  process  of  operat- 
ing on  a  coucli  or  a  bed,  vet,  with  these  inconveniences, 
when  you  are  through  operating  you  can  excuse  your- 
self and  return  to  your  office. 

I  have  practiced  in  the  small  town  and  I  know 
exactly  the  conditions  prevailing  there  and  it  is  quite 
different  from  a  city  practice.  I  have  had  patients 
come  twenty  miles  without  a  word  of  warning  to  have  a 
"mouthful  of  teeth"  extracted,  when  already  enough 
work  was  engaged  for  that  day  to  keep  three  men  busy 
and  what  is  to  be  done  in  such  cases?  If  located  in  a 
town  or  village  in  which  there  is  no  hospital,  yet  on 
certain  occasions  it  is  imperative  to  have  chloroform 
or  ether  administered  in  the  office,  I  would  suggest  the 
following  plan  :  Procure  a  surgical  chair.  These  chairs 
are  not  very  expensive  and  they  are  very  useful.  This 
surgical  chair  can  be  used  as  a  second  chair  when  the 
operating-chair  is  occupied  for  making  examinations, 
treating-  a  tooth,  taking  a  bite,  extracting  a  tooth,  etc., 
and  when  needed  can  be  converted  into  an  operating- 
table. 

There  should  be  a  private  room  for  this  anaesthetic 
■work,  and,  wlien  occasion  arose  to  administer  chloro- 
form or  ether,  roll  the  surgical  chair  into  this  room. 

In  the  year  1906,  there  were  thirty  chloroform 
deaths  reported  that  occurred  in  dental  chairs.  The 
modern  dental  chair  is  not  a  good  anaesthetic  chair  and 
in  jirocuring  a  surgical  chair  you  have  done  much  to 
insure  safety.  No  patient  should  take  ether  or  chloro- 
form with  their  clothing  on.  Especially  in  the  case  of 
women,  everything  should  be  removed  in  the  way  of 


252  General  Anaesthetics  in  Dentistry. 

clothing-  and  a  night-gown  substituted.  You  can  pro- 
vide gowns  for  this  purpose,  or  the  patient  would 
probably  prefer  to  bring  one  of  her  own  if  you  have 
an  opportunity  in  advance  to  suggest  it. 

You  have  done  now  all  that  would  be  done  at  a 
modern  hospital  in  this  respect.  A  couple  of  clean 
sheets  should  be  used  for  a  covering  and  your  patient 
takes  her  place  on  the  table. 

Always  have  the  best  anaesthetist  in  the  county,  and 
always  have  the  same  one  if  possible.  If  there  is  a 
professional  nurse  in  the  town,  have  her,  by  all  means. 

When  the  operation  is  over,  the  nurse  will  relieve 
you  of  all  further  care  and  will  remain  with  the  patient 
while  you  take  up  the  appointments  of  the  day. 

The  nurse  can  make  herself  useful  in  making  the 
patient  comfortable,  and  at  the  proper  time  assist  her 
to  dress,  and  the  patient  leaves  the  ofhce  not  all  blood- 
stained and  nausea-soaked,  as  is  too  often  the  case  at 
the  present  time. 

Remember  that,  when  ether  and  chloroform  are  the 
anaesthetics  employed,  you  are  the  surgeon,  not  the 
anaesthetist,  and  should  not  assume  the  anaesthetic 
responsibility. 

Perfect  yourselves  in  the  administration  of  nitrous 
oxid  and  somnoform;  it  is  seldom  necessary  to  resort 
to  ether  or  chloroform.  I  had  rather  make  two  or  three 
nitrous  oxid  or  somnoform  administrations  for  the 
same  patient  on  as  many  different  days  than  to  have 
ether  or  chloroform  administered  in  my  office,  and  I  am 
confident  such  an  arrangement  is  much  better  for  the 
patient. 


General  AncEsthetics  in  Dentistry.  253 

Dr.  Teters,  of  Cleveland,  and  others  have  become 
so  proficient  in  the  use  of  nitrous  oxid  and  oxygen  as 
to  make  unnecessary  the  employment  of  any  other 
anaesthetic  agent,  no  matter  what  the  operation  or 
how  long  a  time  it  may  consume. 

Occasions  arise,  especially  in  small  towns  and  vil- 
lages, in  which  it  becomes  necessary  to  have  chloro- 
form or  ether  administered  in  the  office  of  the  dentist 
and  there  is  no  way  to  avoid  it.  It  is  well  to  bear  in 
mind,  that,  on  the  average,  ether  is  seven  times  less 
dangerous  than  chloroform.  It  is  no  unusual  occur- 
rence to  pick  up  a  newspaper  and  see  recorded  there 
a  death  in  some  dental  office  resulting  from  the  admin- 
istration of  chloroform  for  the  purpose  of  tooth  extrac- 
tion, but  I  can  not  recall  ever  seeing  recorded  in  the 
public  press  a  death  from  ether  in  the  dental  chair. 

While  the  choice  of  the  anaesthetic  to  be  employed 
is  really  a  matter  for  the  anaesthetist  to  settle  with  the 
patient,  the  dental  surgeon  usually  has  an  opportunity 
to  talk  the  case  over  with  the  patient,  before  the  anaes- 
thetist is  selected  or  consulted  in  the  matter.  In  this 
conversation  you  can  sa}^  "Yes,  it  is  necessary  to  take 
ether.  Whom  do  you  wish  to  administer  the  ether?" 
The  patient  usually  has  a  preference;  if  not,  you  must 
select  an  anaesthetist  and  make  the  arrangement.  Hav- 
ing agreed  upon  the  antesthetist,  call  the  physician  over 
the  'phone  and  say  something  like  this.  "Mrs.  A — 
is  here  at  my  office,  doctor,  and  wishes  you  to  admin- 
ister ether."  The  probability  is,  that  will  decide  the 
anaesthetic  agent  to  be  used  in  this  case,  unless  the 
physician  knows  to  a  certainty  that  ether  is  contra- 


254  General  Ancesfhetics  in  Deniisiry. 

indicated,  and  if  it  is,  of  course  you  want  to  know  it. 
This  patient  might  have  some  pathological  condition 
of  the  kidneys  that  the  physician  knew  about  and  you 
did  not. 

If  you  leave  the  matter  entirely  in  the  hands  of  the 
physician,  making  no  suggestion  whatever,  he  might 
select  chloroform ;  while,  if  you  intimate  that  ether  is 
to  be  the  anaesthetic,  he  takes  it  for  granted  and  ad- 
ministers ether.  Thus  you  can  usually  have  your 
choice  of  the  anaesthetic  agent  to  be  used  in  your  office 
without  apparently  having  any  part  in  the  selection  of 
the  anaesthetic. 

While  the  anaesthetist  is  responsible  for  the  life 
of  the  patient,  should  an  anaesthetic  death  occur  in 
your  office,  your  name  is  always  associated  with  the 
mortality,  a  notoriety  to  be  avoided,  and  for  this  rea- 
son, you  should  be  interested  in  having  the  safest  anaes- 
thetic agent  used  in  every  case. 

If  you  permit  ether  and  chloroform  to  be  adminis- 
tered in  your  office,  you  should  familiarize  yourself  with 
the  physiological  action  of  ether  and  chloroform.  More 
than  this,  you  should  know  and  be  able  to  recognize  the 
slightest  abnormality  on  the  part  of  the  patient.  Aid 
the  anaesthetist  in  every  possible  manner.  Make  a 
study  of  respiration  and  circulation.  Know  the  various 
anaesthetic  stages.  Anticipate  what  might  happen. 
From  your  position  with  both  hands  free  you  may  de- 
tect something  the  anaesthetist,  l^usy  with  adding  more 
of  the  anii'Sthctic  agent  from  time  to  time,  has  not 
oljservcfl,  and  can  call  his  attention  to  it.  As  long  as 
everything  progresses  saiisfacli  >i-ily,  lie   may  not  need 


General  Ancesthetics  in  Dentistry.  255 

your  assistance,  but  if  things  go  wrong  he  will  need 
you,  and  need  you  badly.  This  is  no  time  for  instruct- 
ing you  how  to  do  things,  you  should  know  how,  and 
pitch  in  and  help.  Remember  it  is  your  office  and  your 
patient,  and  partly  your  responsibility. 

You  should  know  the  various  measures  and  reme- 
dies employed  for  resuscitation  and  understand  artifi- 
cial respiration.  The  anaesthetist  may  become  rattled 
and  not  equal  to  the  emergency,  and  your  services 
needed  to  save  the  life  of  the  patient. 

You  should  know  how  to  administer  ether  and  how 
to  administer  chloroform  if  you  permit  their  use  in  your 
office.  Knowing  how  to  administer  these  agents  gives 
you  an  advantage  as  an  assistant.  If  the  anaesthetist 
becomes  careless,  hurries  or  takes  unusual  risks,  you 
observing  this,  are  in  a  position  to  anticipate  what  will 
happen,  and  are  ready  for  the  emergency  that  may 
arise.  Good  anaesthetists  are  rare,  and  simply  because 
a  man  has  the  AI.  D.  degree  he  is  not  necessarily  a 
competent  anesthetist,  especially  in  the  smaller  towns 
and  villages  where  it  is  sometimes  necessary  to  take 
the  physician  that  does  not  happen  to  be  busy.  A  man 
becomes  rusty  and  deficient  in  administering  anaes- 
thetics just  as  in  anything  else ;  so,  when  you  can  pos- 
sibly do  so,  employ  the  man  in  your  community  that 
has  the  largest  anaesthetic  practice. 

Sulphuric  Ether. 

Valerius  Cordus  discovered  sulphuric  ether  in  1540, 
but  not  till  three  centuries  later  were   its  anaesthetic 


256  General  Ancesthetics  in  Dentistry. 

properties  recognized  by  Morton,  an  American  dentist, 
in  the  year  1846. 

Sulphuric  ether,  vinous  ether,  ethylic  ether  has  the 
chemical  formula  C4H10O. 

Ether  is  a  transparent,  colorless,  highly  volatile  and 
inflammable  fluid  with  a  pungent  odor  and  a  burning 
taste.    It  mixes  freely  with  alcohol  and  chloroform. 

It  is  important  to  remember  that  ether  is  highly 
inflammable  and  burns  with  a  white  luminous  flame. 
It  should  never  be  administered  in  a  room  that  is 
lighted  with  a  candle,  lamp,  gas  jet  or  any  kind  of  an 
open  flame.  Actual  cautery  must  not  be  used  about  the 
mouth  or  nose  when  ether  is  being  administered.  Cases 
are  on  record  in  which  the  patient  has  been  severely 
burned,  the  inhaler  igniting  and  the  face  burned  deeply, 
involving  the  nose,  throat  and  lungs,  when  actual  cau- 
tery was  used. 

There  are  two  methods  of  administering  ether;  one 
is  known  as  the  "close,"  and  the  other  the  "open" 
method. 

The  close  method  is  used  almost  universally  abroad, 
while  the  open  method  is  used  almost  exclusively  in 
this  country.  It  is  difificult  to  understand  why  this 
should  be,  yet  it  is  a  matter  of  history.  Still  more 
mysterious  is  the  fact  that  the  highest  angesthetic 
authorities  in  both  England  and  Scotland  maintain 
that  a  satisfactory  anaesthesia  can  not  be  induced  by 
the  open  method. 

Hewitt  says,  "As  a  general  rule,  it  is  impossible 
to  produce  deep  anaesthesia  by  this  (the  open)  system, 
although  it  may  be  used  in  infants,  in  extremely  ex- 


General  AncEsthetics  in  Dentistry.  257 

hausted  subjects,  or  in  patients  who  have  been  for 
some  time  deeply  anaesthetized,  and  who,  in  conse- 
quence, require  minimal  insensibility." 

Luke,  of  Edinburgh,  in  the  British  Medical  Journal 
of  March  17,  1906,  writes:  "An  American  surgeon  on 
a  visit  to  this  country  recently  told  me  that  a  lady 
gave  his  anaesthetics  for  him,  combining  this  duty  with 
typewriting  and  stenography.  She  possessed  no  medi- 
cal qualification  of  any  description.  I  inquired  as  to 
the  method  she  adopted,  and  was  told  she  gave  ether 
to  all  the  cases  by  the  drop  method,  on  an  open  mask, 
and  apparently  the  results  were  most  satisfactory. 
While  ready  to  believe  that  there  were  but  a  few  fatali- 
ties when  such  a  method  was  employed,  I  at  once  came 
to  the  conclusion  that  neither  he  or  the  lady  had  much 
conception  of  what  anaesthesia  really  meant  for  every- 
one who  knows  anything  of  the  subject  must  be  aware 
that  it  is  morally  impossible  to  produce  satisfactory 
ansesthesia  in  adults  by  such  a  method  with  ether  un- 
less morphine  or  scopolamine  is  called  into  requisition 
as  an  adjunct."  The  open  method  here  referred  to  is 
used  all  over  the  United  States  hundreds  of  times  a 
day,  yet  these  eminent  authorities  deny  that  satisfac- 
tory anaesthesia  can  be  induced  by  the  drop  method  of 
administering  ether.  I  doubt  if  you  ever  have  or  ever 
will  witness  any  other  than  the  drop  method  in  this 
country. 

The  patient  should  be  especially  prepared  in  ad- 
vance when  ether  or  chloroform  are  to  be  administered. 
The  night  before  the  operation  the  patient  should 
be    oriven    a    srood    dose    of    castor    oil.      This    should 


258  General  Anesthetics  in  Dentistry. 

be  followed  next  morning  by  a  dose  of  salts  and  the 
patient  given  during  the  day  very  light  digestible  food, 
food.  If  the  operation  is  to  be  performed  next  morning 
about  eight  o'clock,  no  breakfast  should  be  eaten. 

'Even  for  my  ether  patients  I  prefer  to  use  a  mouth- 
prop  during  the  administration  of  the  anaesthetic.  For 
this  purpose  I  prefer  the  ordinary  soft  rubber  mouth- 
prop,  thoroughly  sterilized,  about  which  a  string  is 
tied.  In  the  first  and  second  stages  of  ether,  the  mas- 
ticatory muscles  frequently  contract,  and,  if  the  patient 
should  happen  to  vomit  at  this  time  or  the  tongue  be 
swallowed,  the  situation  may  become  a  serious  one. 
Another  reason  is  this:  the  masseter  muscle  is  some- 
times the  last  one  in  the  body  to  relax.  Surgical  anaes- 
thesia has  already  been  induced  and  there  is  no  reason 
why  the  operation  could  not  be  commenced,  if  the 
mouth  was  only  open.  Frequently  a  depth  of  anes- 
thesia entirely  unnecessary  for  the  operation  under 
consideration  must  be  had  in  order  to  relax  these  mus- 
cles and  force  the  jaws  apart  sufficiently  wide  for  the 
operation. 

The  face  of  the  patient  should  be  smeared  with 
vaseline.  Ether  is  irritating  and  if  it  comes  in  contact 
with  the  mucous  membrane  it  burns.  Have  the  pa- 
tient close  the  eyes  and  place  over  each  eyelid  a  good- 
sized  piece  of  moist  sterilized  absorbent  cotton  or 
surgeon's  gauze.  This  is  to  prevent  ether  getting  into 
the  eyes.  Then  wrap  a  towel  around  the  head  well 
down  over  the  eyes  almost  to  the  entrance  of  the  nares. 
This  is  to  hold  the  cotton  or  gauze  on  the  eyes  and  1.o 
protect   the   cheeks.      Fasten   this   towel    or   surgeon's 


General  Anccsthetics  in  Dentisiry.  259 

bandage  tightly  with  a  safety-pin.  Place  another 
towel  under  the  chin  bringing  it  well  up  to  the  lower 
lip  and  around  back  of  the  neck.  This  protects  the 
lower  part  of  the  face  and  cheeks  also. 

The  best  inhaler  is  the  improved  Esmarch.  This 
should  'be  boiled,  of  course,  each  time  after  using  and 
also  before  using.  Two  thicknesses  of  stockinet  are 
used  wuth  this  inhaler;  and  the  stockinet  destroyed 
after  using.  Prepare  a  cork  for  the  ether  can  with 
a  slit  on  two  sides.  In  one  of  these  slits  or  grooves 
place  a  thin  wick  of  absorbent  cotton  extending  out 
about  an  inch.  Alice  Magaw  recommends  two  cans, 
one  with  a  large  dropper  to  be  used  in  the  beginning  till 
the  patient  is  fully  under  the  anassthetic,  then  changed 
to  the  can  with  the  small  dropper  to  be  used  during- 
the  operation. 

The  patient  must  now  be  handled  as  described  in 
the  "Elements  of  Success"  lecture.  Get  your  patient 
in  a  tranquil  frame  of  mind,  dispel  fear,  suggest  the 
things  you  want  them  to  see  and  feel  so  strongly  that 
they  will  see  and  feel  them.  In  this  frame  of  mind,  it 
does  not  require  much  ether  to  anaesthetize  a  patient 
or  to  maintain  anaesthesia.  I  have  come  to  believe  the 
success  one  attains  in  administering  anaesthetics  de- 
pends largely  on  the  anaesthetist;  his  personality,  his 
manner,  the  impression  he  makes  on  the  patient  is 
nine-tenths  the  battle. 

On  this  point,  Alice  MagaAv  says :  "Suggestion  is 
a  great  aid  in  producing  a  comfortable  narcosis.  The 
anaesthetist  must  be  able  to  inspire  confidence  in  the 
patient,  and  a  great  deal  depends  upon  the  manner  of 


260  General  Ancesthetics  in  Dentistry. 

approach.  One  must  be  quick  to  notice  the  tempera- 
ment, and  decide  which  mode  of  suggestion  will  be 
the  most  effective  in  the  particular  case ;  the  abrupt, 
crude,  and  very  firm,  or  the  reasonable,  sensible  and 
natural.  The  latter  mode  is  far  better  in  the  majority 
of  cases.  The  subconscious  or  secondary  self  is  par- 
ticularly susceptible  to  suggestive  influence;  therefore, 
during  the  administration,  the  anaesthetist  should  make 
those  suggestions  that  will  be  most  pleasing  to  this 
particular  subject.  Patients  should  be  prepared  for 
each  stage  of  the  ansesthesia  with  an  explanation  of 
just  how  the  ansesthetic  is  expected  to  affect  him ;  talk 
him  to  sleep,  with  the  addition  of  as  little  ether  as 
possible.  We  have  one  rule :  Patients  are  not  allowed 
to  talk,  as  by  talking  or  counting,  patients  are  more 
apt  to  become  more  noisy  and  boisterous.  Never  bid  a 
patient  to  'breathe  deep,'  for  in  so  doing  a  feeling  of 
suffocation  is  sure  to  follow,  and  the  patient  is  also 
apt  to  struggle." 

The  amount  of  ether  required  for  a  given  patient 
is  always  an  unknown  quantity.  The  rule  is  to  give 
the  required  amount  whatever  that  may  be  and  no 
more.  The  temperament  of  the  patient,  the  mental 
attitude,  the  time  consumed  in  each  individual  case  to 
induce  surgical  ansesthesia  all  play  a  part  in  determin- 
ing the  amount  of  ether  necessary  for  the  case  in  hand. 

The  ether  is  fed  drop  by  drop,  no  attempt  being 
made  to  exclude  air  in  the  beginning.  It  requires  a 
deeper  anaesthesia  at  the  time  of  starting  the  operation 
than  later.  Having  induced  surgical  ansesthesia  the 
can  being  used  is  set  aside  and  the  one  with  the  small 


General  AncBsthetics  in  Dentistry.  261 

dropper  substituted.  It  requires  but  very  little  ether 
to  maintain  surgical  ansesthesia.  Results  obtained  by 
Alice  Magaw,  anaesthetist  to  St.  Mary's  Hospital, 
Rochester,  Minnesota,  at  the  Mayo  clinic,  are  almost 
beyond  belief.  Ether  is  her  favorite  anaesthetic,  she 
uses  the  open  method  altogether,  and  obtains  surgical 
anassthesia  in  from  three  to  five  minutes.  The  small 
amount  of  ether  used  by  this  anaesthetist,  as  compared 
to  the  quantity  ordinarily  used  by  other  anaesthetists  is 
astonishing.  In  reply  to  the  question,  "How  do  you 
do  it?"  she  will  make  answer,  "I  simply  talk  them  to 
sleep." 

I  have  maintained  for  years  that  the  administration 
of  anaesthetics  is  not  a  very  dangerous  procedure,  and 
that  when  the  subject  was  better  understood  and  more 
rational  methods  employed  in  administering  anaes- 
thetics, a  mortality  would  rarely  occur  as  the  result  of 
the  anaesthetic,  per  se.  Alice  Magaw  is  doing  a  valiant 
service  and  everyone  that  visits  Rochester  to  see  the 
Mayos  operate,  are  impressed  with  her  marvelous 
work.  With  a  record  of  18,000  angesthesias  she  has 
never  had  a  death  as  the  result  of  the  anaesthetic. 

In  regard  to  dangers,  she  says :  "Should  ether  pro- 
duce difficult  breathing,  profuse  secretion  of  mucus,  or 
cough,  lift  the  mask  from  the  face,  allow  a  liberal 
amount  of  air,  and  continue  with  the  ether.  In  giving 
plenty  of  air,  when  needed,  and  less  anaesthetic,  we  have 
found  little  use  for  an  oxygen  tank,  a  loaded  hypo- 
dermic syrin^-e,  or  tongue  forceps.  It  is  far  better  for 
the  anaesthetist  to  become  skillful  in  watching  for 
symptoms  and  prevent  them,  than  to  become  so  pro- 


262  General  Ancesthetics  in  Dentistry. 

ficient  in  the  use  of  the  three  articles  mentioned." 

Every  precaution  should  be  taken  in  the  administra- 
tion of  ether  to  admit  air  freely.  Proper  elevation  of 
the  head  has  much  to  do  with  the  admission  or  exclu- 
sion of  air.  "Proper  elevation  of  the  head  will  relax 
all  tissues  of  the  neck  and  give  more  freedom  in  breath- 
ing. This  also  can  be  said  of  the  jaw.  Holding  the 
jaw  up  and  forward  and  keeping-  it  in  position  so  that 
the  patient  gets  the  greatest  amount  of  air  possible  is 
an  important  feature  in  giving  an  anesthetic. 

Chloroform. 

Sir  James  Y.  Simpson  was  the  first  to  call  attention 
to  the  anaesthetic  properties  of  chloroform.  He  was 
one  of  the  first  to  make  use  of  ether  as  an  anaesthetic, 
and,  in  seeking  to  find  some  agent  that  possessed  the 
narcotic  properties  of  ether,  yet  was  less  irritating  and 
more  pleasant  to  inhale,  in  1847,  announced  chloroform 
to  be  that  agent. 

Chloroform  was  hailed  with  delight,  and  enthusi- 
astically received  on  all  sides,  and  at  first  was  thought 
to  be  absolutely  devoid  of  danger.  First  one  death, 
then  another,  made  surgeons  more  cautious,  and  ether, 
so  nauseating  and  with  all  its  disagreeable  effects,  is 
more  universally  employed  than  any  other  general 
an£esthetic. 

It  was  a  great  disappointment  to  everybody  that 
so  many  mortalities  occurred  from  chloroform  anaesthe- 
sia, because  its  effects  were  so  much  more  pleasant  in 
every  particular  than  anaesthesia  induced  by  ether,  and 
its  briefer  period  of  induction  was  greatly  in  its  favor. 


General  Ancesthetics  in  Dentistry.  263 

I  am  satisfied  that  chloroform  is  not  as  dangerous  an 
anassthetic  as  the  mortalities  following  its  use  would 
indicate.  Some  men  have  made  thousands  of  chloro- 
form anaesthesias  and  have  never  seen  a  chloroform 
death.  This  would  seem  to  indicate  that  some  men  are 
either  more  careful  than  others,  or  that  they  have  a 
safer  method  of  inducing  chloroform  anaesthesia. 

When  a  towel  folded  in  the  shape  of  a  cone  was 
used  as  a  chloroform  inhaler,  deaths  were  far  more 
frequent  than  now.  Chloroform  is  nearly  four  times  as 
heavy  as  air  and  when  a  cone  is  used  as  an  inhaler,  and 
held  over  the  nose  and  mouth  patients  are  drowned. 
The  drop  method  should  always  be  employed  using  an 
Esmarch  or  similarly  constructed  inhaler.  In  the  be- 
ginning the  chloroform  vapor  should  be  very  mild. 
Two  per  cent,  of  chloroform  is  sufficient  to  anaesthetize 
a  patient  and  one  per  cent,  is  all  that  is  needed  to  main- 
tain anaesthesia.  AVhen  we  witness  a  chloroform  anaes- 
thesia, as  the  agent  is  usually  administered,  it  is  aston- 
ishing that  many  more  mortalities  do  not  occur.  It 
makes  no  difiference  how  safe  a  given  anassthetic  agent 
may  be  in  the  hands  of  a  certain  anaesthetist,  the  gen- 
eral average  of  mortalities  occurring  from  the  use  of 
an  anaesthetic  is  what  determines  its  relative  safet}'-. 
Judged  in  this  way,  chloroform  has  a  death  rate  several 
times  greater  than  ether  and  the  latter  agent  for  that 
reason  has  become  more  generally  employed  in  sur- 
gical work. 

Chloroform  was  independently  discovered  by  Guth- 
rie. Liebig  and  Soubeiran  in  the  year  1831,  but  not  till 
1847  was  it  known  to  possessi  anassthetic  properties. 


264  General  AncEsthetics  in  Dentistry. 

It  is  colorless,  volatile  liquid  with  a  penetrating 
odor,  and  sweetish  taste  producing  a  burning  sensa- 
tion. 

For  anaesthetic  purposes,  only  the  purest  makes 
should  be  employed.  It  is  well  to  remember  that 
chloroform  should  be  protected  from  the  light.  Ram- 
say has  m.ade  the  statement  that  chloroform  exposed 
to  the  light  and  air  in  the  course  of  a  short  time  leads 
to  the  formation  of  carbonyl  chloride.  For  this  reason, 
it  is  a  good  plan  to  keep  chloroform  in  a*  dark  place. 
Some  manufacturers  with  this  end  in  view  use  blue 
glass  bottles  as  containers.  Others  cover  the  bottles 
containing  chloroform  with  blue  paper. 

There  are  some  simple  tests  that  should  be  remem- 
bered. It  is  a  good  plan  to  purchase  chloroform  in 
quarter-pound  bottles  rather  than  larger-sized  pack- 
ages, and  these  are  not  so  apt  to  change  chemically  or 
become  impure  before  using  as  larger  packages. 

Pure  chloroform  should  be  absolutely  neutral  to 
litmus  paper. 

It  should  have  a  boiling-point  of  one  hundred  and 
forty  degrees  Fahrenheit. 

It  should  have  a  mild,  non-irritating  odor. 

It  should  be  transparent  and  colorless. 

Shaken  with  sulphuric  acid,  there  should  be  no  dis- 
coloration. 

With  a  solution  of  argentum  nitrate,  it  should  not 
form  a  precipitate. 

When  heated  to  the  boiling-point  with  caustic  pot- 
ash, it  should  not  show  brown. 

If  placed  on  the  bottom  of  a  tumbler  or  in  a  watch 


General  AncBsthetics  in  Dentistry.  265 

crystal  and  allowed  to  evaporate,  it  should  leave  no 
residue. 

To  be  absolutely  safe,  it  is  better  to  open  a  fresh 
original  package  each  time  than  to  take  the  slightest 
risk  of  using  a  bottle  that  has  been  standing  around. 
Chloroform  is  not  expensive  and  no  risks  should  be 
assumed.  The  patient  should  be  prepared  in  advance 
for  chloroform  administration,  and  all  that  has  been 
said  in  regard  to  preparation  of  the  patient  when  ether 
was  to  be  taken,  is  applicable  here.  This  is  more  than 
true  in  regard  to  protecting  the  eyes  and  cheeks  from 
having  chloroform  accidentally  come  in  contact  with 
them,  because  it  is  a  stronger  irritant  than  ether  and 
unfortunately  some  patients  have  been  badly  burned 
from  the  liquid  chloroform  coming  in  contact  with  the 
face  and  eyes. 

If  you  are  aware  at  any  time  of  chloroform  or  ether 
getting  into  the  eye,  follow  it  with  a  drop  of  sweet  oil. 
This  will  prevent  conjunctivitis.  The  position  of  the 
patient  is  a  very  important  thing  in  chloroform  anaes- 
thesia. The  sitting  posture  should  never  be  allowed  in 
chloroform  narcosis.  The  patient  should  be  placed  on 
his  back,  his  head  being  on  a  level  with  the  body  or 
only  slightly  elevated.  There  is  a  diminution  of  blood 
pressure  in  chloroform  anaesthesia,  and  it  is  important 
that  the  heart  be  saved  as  much  work  or  effort  as  pos- 
sible, and  it  is  self-evident  the  more  nearly  erect  the 
posture  of  the  patient  the  harder  the  heart  must  pump 
to  supply  blood  to  the  brain.  Anaemia  of  the  brain  is 
one  of  the  causes  of  circulatory  arrest. 

Even  if  the  patient  has  been  placed  in  the  correct 


266  General  Ancesihetics  in  Dentistry. 

anaesthetic  position  for  chloroform  administration,  if 
the  operation  is  that  of  extracting  teeth,  when  ready  to 
operate,  if  the  chair  is  raised  to  a  position  convenient 
for  the  operator,  it  is  always  done  at  great  risk.  If 
the  heart  is  unable  to  respond,  or  if  the  task  is  met  by 
an  effort,  the  imposed  strain  to  meet  the  conditions 
may  be  such  as  to  result  in  heart  failure. 

Remember  this:  if  chloroform  should  be  adminis- 
tered in  your  office  for  the  purpose  of  tooth  extraction, 
no  matter  how  much  the  position  of  the  patient  may 
inconvenience  you,  if  it  is  possible  to  do  so,  operate 
without  raising  the  head  at  all;  but,  if  the  head  must  be 
raised,  see  to  it  that  it  is  raised  not  one  inch  higher  than 
necessary.  I  believe  that  many  of  the  mortalities  oc- 
curring in  dental  chairs  as  the  result  of  chloroform 
anaesthesia  are  really  caused  by  having  the  head  of  the 
patient  unduly  elevated  during  the  induction  of  the 
anaesthesia,  or  by  suddenly  elevating  the  chair  to  the 
ordinary  extracting  position, 

A¥hen  we  take  into  consideration  that  the  cloth- 
ing of  the  patient  is  rarely,  if  ever,  removed  when 
chloroform  is  administered  in  a  dental  chair,  or  that 
any  preliminary  physical  preparation  has  been  made, 
and  that  little  or  no  attention  is  paid  to  the  position 
of  the  patient  in  the  chair,  and  further,  when  surgical 
anaesthesia  has  been  induced,  the  back  of  the  chair  is 
raised  with  a  jerk,  bringing  the  patient  suddenly  to 
the  sitting  posture,  it  is  not  surprising  that  so  many 
chlorrtform  mortalities  occur  in  the  dental  office.  If 
the  dental  surgeon  makes  no  other  preparation  than 
the  dental  chair  in  his  office  for  the  administration  of 


General  Ancesthetics  in  Dentistry.  267 

chloroform,  for  the  sake  of  the  patient,  for  your  own 
sake,  and  for  the  sake  of  chloroform  itself,  refuse  abso- 
lutely to  permit  this  anaesthetic  to  be  administered  in 
your  ofBce  for  the  operation  of  tooth  extraction. 

The  eyes  and  cheeks  having  been  properly  pro- 
tected, the  patient  placed  in  the  chloroform  position, 
the  ansesthetist  assumes  a  comfortable  position,  and 
takes  the  Esmarch  or  other  inhaler  in  hand,  and,  by 
means  of  the  drop  method,  induces  anaesthesia.  The 
milder  the  better  in  the  beginning,  gradually  increasing 
the  amount  as  the  patient  is  ready  for  it. 

Hewitt,  of  London,  has  prepared  the  most  accurate 
and  valuable  table  I  have  ever  seen,  setting  forth  the 
degrees  or  stages  of  ansesthesia,  and  I  recommend  that 
it  be  studied  closely. 

The  treatment  of  accidents  or  dangers  arising  dur- 
ing ether  and  chloroform  ansesthesia  will  be  found  in 
the  lecture  entitled  "Difficulties  and  Dangers  Incident 
to  Administering  General  Anaesthetics  in  Dental  Prac- 
tice and  How  to  Meet  Them." 


268  General  Ancesthetics  in  Dentistry. 

Dr.  Frederick  W.  Hewitt's  Table,  Showing  the  De- 
grees or  Stages  in  the  Action  of  the  Chief  General 
Anaethetics  upon  the  Human  Organism,  and  the 
Phenomena  which  Usually  Characterize  These 
Stages  when  No  Complication,  Asphyxial  or  Trau- 
matic is  Present. 

Effects. 
1.    Stage  of  Analgesia. 

Excessive  ideation ;  disturbances  of  judgment,  con- 
trol, and  volition. 

Analgesia. 

Vertigo  and  loss  of  power  of  maintaining  equilib- 
rium. 

Pleasurable  or  distressing  sensations. 

Disturbances  (exaggeration  or  diminution)  of  com- 
mon sensibility  and  of  special  senses. 

Misinterpretation  of  external  impressions. 

Emotional  disturbances;  e.  g.,  laughter  and  crying. 

Reflexes  well  marked  and  often  exaggerated ;  sen- 
sory stimuli  produce  co-ordinated  and  apparently  pur- 
posive movements. 

Loss  of  povv^er  and  remembering  (fixing)  sensory 
impressions. 

Dreams. 

Rise  of  blood-pressure  and  increase  of  cardiac  action. 

Respiration  increased  but  regular  and  free,  unless 
interfered  with  by  emotional  causes  or  by  direct  irri- 
tation of  the  anaesthetic,  inducing  cough,  "holding  of 
breath,"  deglutition  movements,  retching  or  vomiting. 

Pupils  dilated. 


General  Ancesthetics  in  Dentistry.  269 

2.    Stage  of  Light  Anaesthesia. 

Complete  loss  of  consciousness. 

Delirium;  articulate  speech  passing  into  unintelli- 
gible muttering. 

Respiration  still  deeper  and  quicker  than   normal ; 
often  irregular  and  impeded  by 

General  tonic  muscular  spasm,  deglutition,  closure 
of  glottis,  spasm  of  jaws,  etc. 

Clonic  muscular  spasm. 

Reflexes  still  persist;  but  motor  results  of  stimuli 
devoid  of  purposive  character. 

Inarticulate  phonated    (expiratory)    sounds. 

Coiighing,  retching,  vomiting. 

Heart's   action    still   excited    (much    dependent    on 
character  of  breathing.) 

Pupils  smaller. 

3.     Stage  of  deep  anaesthesia  or  narcosis. 

Relaxation  of  most  muscles. 

Breathing  regular,  often  softly  snoring  or  stertorous. 

Decrease   of   respiratory   changes;   fall   of   temper- 
ature. 

Increase  fall  of  blood-pressure.     (Chloroform.) 

Heart's  action  weakened,  variable  degree  of  cardiac 
dilitation. 

Loss  of  corneal,  pharyngeal,  laryngeal,  patellar,  and 
most  but  not  all  reflexes. 

Pupils  larger. 


270  General  Ancesthetics  in  Dentistry. 

4.     Stage  of  Bulbar  Paralysis. 

Loss  of  bladder  distension,  rectal,  and  other  very 
late  (e.  §;■.,  certain  peritoneal)  reflexes. 

Breathing"  becomes  shallow. 

Increased  lividity  or  pallor. 

Breathing-  ceases  (paralysis  of  respiratory  centers), 
loss  of  respiratory  reflexes. 

Paralysis  of  vaso-motor  centers. 

Feeble,  irregular  cardiac  action;  complete  cardio- 
vascular paralysis. 

Widely  dilated  pupils. 

Separation  of  eyelids. 

Death. 


General  AncBsthetics  in  Dentistry.  271 


LECTURE  XXI. 

Difficulties    and    Dangers    Incident    to    Administering 

General  Anaesthetics  in  Dental  Practice  and 

How  to  Meet  Them. 

One  of  the  most  trying  things  connected  with  anaes- 
thetic administration  is  the  condition  of  fear  or  dread 
on  the  part  of  the  patient.  The  more  frightened  the 
patient,  the  more  difficult  it  is  to  successfully  anaesthet- 
ize the  patient.  As  I  have  already  said  in  a  previous 
lecture,  I  much  prefer  to  anaesthetize  a  patient  with 
an  impaired  kidney,  a  diseased  lung  and  an  abnormal 
heart  in  a  tranquil  state  of  mind,  devoid  of  fear,  than 
to  administer  an  anaesthetic  to  a  patient  perfectly 
healthy  who  takes  the  chair  trembling  with  fear.  To 
dispel  fear  is  the  duty  of  every  anaesthetist,  and  we 
have  already  spoken  of  this  at  some  length  in  the  lec- 
ture on  "Elements  of  Success." 

One  of  the  most  difficult  things  about  an  anaesthetic 
practice  is  to  get  the  w^omen  to  remove  their  corsets. 
They  will  insist  that  the  corset  is  very,  very  loose  and 
there  is  no  necessity  of  even  making  it  looser,  and  as 
to  removing  it  they  often  refuse  to  do  so  at  first,  and 
then  only  under  protest  when  informed  that  I  will  not 
operate  for  them  unless  the  corset  is  removed.  This 
is  a  rule  that  should  be  insisted  upon  and  never  vio- 


272  General  Ancesthetics  in  Dentistry. 

lated.  In  making  an  appointment,  you  will  do  well  to 
remind  the  patient  that  the  corset  must  be  removed 
and  request  them  to  come  dressed  loosely  and  many 
will  take  the  hint  and  not  wear  a  corset  to  the  office. 
In  speaking  of  this,  on  one  occasion,  at  a  dental  clinic. 
Dr.  McClanahan,  of  Iowa  Falls,  told  me  that  he  had  a 
patient  that  insisted  that  her  corset  was  very  loose  and 
he  took  her  word  for  it.  This  patient  as  he  adminis- 
tered the  anjesthetic  breathed  imperfectly  and  then 
ceased  to  breathe.  This  "loose  corset"  was  so  tight 
that  the  doctor  with  all  his  strength  could  not  force  it 
together  to  unhook  it  and  was  compelled  to  cut  the 
string  with  a  knife,  and  the  patient  breathed  again. 

The  corset  question  has  also  been  more  thoroughly 
considered  in  the  lecture  on  "Elements  of  Success." 
But  let  me  say  just  here,  that  many  dentists  have 
marvelled  at  the  very  few  nausea  cases  that  I  have 
reported  in  my  practice,  only  ten  in  over  4,000  som- 
noform  anaesthesias,  where  blood  has  not  been  swal- 
lowed. I  account  for  this  not  altogether,  but  largely 
because  my  patients  are  anaesthetized  without  their 
corsets. 

Little  children  nearly  always  rebel  and  cry  just  as 
you  attempt  to  insert  the  mouth-prop.  This  is  always 
unfortunate,  but  can  not  be  helped.  I  prefer  somno- 
form  to  nitrous  oxid  as  an  anaesthetic  for  little  chil- 
dren. One  reason  is  that  with  nitrous  oxid  the  time 
and  attention  of  the  assistant  is  entirely  taken  up  in 
looking  after  the  anesthetic,  while  with  somnoform 
the  assistant  has  nothing  to  do  but  to  help  with  the 
patient.     The  little  patient,  becoming  nervous  and  re- 


General  Ancesthetics  in  Dentistry.  273 

belling",  really  needs  someone  who  understands  how  to 
keep  her  from  sliding  down  in  the  chair  and  getting 
away  from  you,  or  to  keep  the  hands  from  grabbing 
the  inhaler  or  steady  the  head  as  it  is  turned  violently 
from  one  side  to  the  other.  With  nitrous  oxid,  the 
assistant  having  all  she  can  attend  to,  especially  if 
oxygen  is  to  be  used  with  the  nitrous  oxid,  the  parenf 
or  some  friend  has  to  assist  in  holding  the  patient  and 
this  should  never  be  permitted  when  nitrous  oxid  is 
the  ansesthetic  agent  employed.  As  soon  as  the  patietit 
becomes  a  little  cyanotic,  the  friend  or  parent,  which- 
ever it  may  be/frequently  becomes  hj'-sterical,  thinking 
the  child  is  dying,  insists  that  you  discontinue,  and  if 
you  do  and  extract,  then  the  child  yells  and  screams 
as  loud  as  she  can,  then  the  mother  contends  that 
you  not  only  nearly  killed  the  child  with  the  anaesthetic, 
but  that  you  hurt  her  besides.  In  administering  nitrous 
oxid,  no  member  of  the  family  or  near  relative  should 
be  allowed  to  stand  where  they  can  see  the  patient. 
It  is  much  better  that  they  should  not  be  allowed  even 
in  the  operating-room.  When  I  am  using  somnoform, 
I  prefer  the  parents  or  friends  to  remain  near  the  pa- 
tient till  I'am  ready  to  begin  to  extract.  At  the  nod 
of  my  head,  as  previously  arranged,  the  parent  or  friend 
leaves  the  room,  and  I  call  them  as  soon  as  the  ex- 
tracting is  completed  and  have  them  stand  in  front  of 
the  little  patient  so  she  will  see  them  as  soon  as  she  is 
sufficiently  awake.  Under  somnoform  ansesthesia,  the 
patient  has  a  quiet,  sleepHke  appearance,  beautiful  to 
behold  and  the  parent  seeing  the  child  sleeping  away 
so  beautifully  is  not  as  apprehensive  of  fear  or  does 


274  General  Ancssthetics  in  Dentistry. 

she  suffer  as  much  anxiety  as  when  she  does  not  know 
what  is  being  done  or  going  on.  To  return  to  the  pa- 
tient again,  I  said  when  you  begin  to  insert  the  mouth- 
prop  the  patient  often  rebels  and  cries  aloud  attempting 
to  get  his  liberty.  Somnoform  is  supreme  in  these 
cases,  for  it  onh^  takes  a  very  little  of  it  to  quiet  the 
patient,  usually  one  inhalation  and  all  crying  is  over 
and  the  ansesthesia  progresses  evenly  without  a 
struggle. 

Whether  using  nitrous  oxid  or  somnoform,  you 
must  be  careful  with  crying  children.  Some  children 
hold  their  breath  as  long  as  they  can,  then  exhale,  which 
is  followed  by  a  very  deep  inhalation.  Here  is  a  dan- 
ger point  no  matter  what  the  anaesthetic.  With  chloro- 
form vapor,  enough  might  be  inhaled  at  that  one  inhal- 
ation to  cause  paralysis  of  the  respiration  or  circulation. 
The  same  is  true  of  somnoform.  Hewitt  says  the 
greatest  care  must  be  exercised  just  here  when  nitrous 
oxid  is  the  anaesthetic  agent  lest  the  patient  become 
dangerously  asphyxiated. 

At  this  first  inhalation,  after  the  breatli  has  been 
held,  no  matter  what  ansesthetic  agent  is  being  used, 
be  sure  that  only  a  small  part  of  the  anaesthetic  vapor 
be  allowed  to  enter  the  lungs.  With  chloroform,  ether 
or  nitrous  oxid  as  usually  administered,  the  amount 
of  anaesthetic  inhaled  at  this  first  inhalation  is  a  matter 
of  guess-work.  With  the  Stark  inhaler,  the  amount  of 
ethyl  chloride  or  somnoform  can  be  gauged  to  a  nicety. 
With  the  inhaler  held  tightly  against  the  face  you 
can  adjust  the  Stark  appliance  so  as  to  admit  just  as 
small  an  amount  of  the  anaesthetic  as  you  desire.     Or, 


General  AncestheHcs  in  Dentistry.  275 

at  this  first  inhalation,  if  using  the  Stark  inhaler,  you 
can  exclude  all  anaesthetic  and  the  patient  inhales  all 
air,  and  at  the  next  inhalation  or  even  the  next  after 
that,  when  the  patient  is  not  breathing  so  deeply,  just 
a  trace  can  be  admitted.  Enough  goes  along  with  this 
first  inhalation,  if  the  anaesthetic  is  somnoform  or  eth3'l 
chloride,  to  quiet  the  patient  and  the  breathing  be- 
comes regular  and  there  is  seldom  any  further  trouble ; 
but,  if  nitrous  oxid  is  the  anaesthetic  agent  being  used, 
the  first  two  or  three  inhalations  stimulates  the  pa- 
tient and  makes  him  more  difficult  to  control. 

The  following  case  is  illustrative  of  what  can  be 
done  in  these  cases  of  nervous  children.  Not  very 
long  ago  I  was  asked  to  administer  somnoform  for  Dr. 
AV —  at  Drake  University  Medical  College,  the  opera- 
tion being-  a  double  tonsilotomy.  One  o'clock  was  the 
appointed  hour.  When  I  walked  into  the  college  cor- 
rider,  a  little  girl,  sitting  there  waiting,  commenced  to 
cry  and  screamed  so  she  could  be  heard  all  over  the 
building  and  out  in  the  street.  I  knew  that  this  was  the 
patient  without  being  told.  She  kept  up  this  yelling 
for  about  five  minutes  and  by  the  time  we  were  ready 
for  her  she  was  almost  frantic.  Not  a  very  favorable 
outlook  for  either  myself  or  somnoform  when  I  wished 
to  appear  to  good  advantage  before  the  students.  She 
had  to  be  dragged  into  the  operating-room  and  lifted 
on  the  table  screaming  that  she  "would  not  take  that 
stuff."  she  would  not  open  her  mouth  and  have  her 
tonsils  out.  AMth  a  student  holding  each  leg  and  each 
arm  and  another  holding  or  steadying  her  head,  as  she 
opened  her  mouth  to  protest,  I  slipped  in  a  Whitehead 


276  General  AncBsihetics  m  Dentistry. 

mouth-prop.  With  her  head  held  firmly,  I  allowed 
enough  somnoform  to  enter  with  the  first  inhalation 
to  quiet  her  and  a  little  more  the  next  time,  then  about 
two  inhalations  with  all  air  excluded  and  Dr.  W — 
removed  the  left  tonsil,  then  the  right,  and  they  were 
both  out  at  least  30  seconds  before  she  moved  a  muscle 
or  changed  the  expression  of  her  face  and  she  awoke 
good-natured  and  did  not  even  cry. 

Mental  and  Muscular  Excitement. — "Amongst  the 
common  causes  of  excitement  and  struggling  may  be 
mentioned :  the  employment  of  an  inhaler  whose  air- 
way is  or  has  become  restricted ;  undue  vapor  concen- 
tration ;  too  rapid  an  administration ;  and  handling  or 
necessarily  interfering  with  the  patient  whilst  semi- 
conscious." (Hewitt.)  When  proper  care  is  taken  and 
rational  methods  adopted,  struggling  and  excitement 
are  exceptional.  If  an  inhaler  is  employed,  in  which 
the  amount  of  air  is  restricted,  this  may  lead  to  a  vio- 
lent state  of  excitement  if  nitrous  oxid  is  being  admin- 
istered. Or,  if  too  much  anaesthetic  is  suddenly  in- 
haled, this  may  result  in  muscular  spasm,  leading  to 
asphyxial  conditions.  There  are  a  few  patients,  how- 
ever, who  become  excited,  boisterous  and  violent,  even 
though  every  precaution  known  is  taken  in  administer- 
ing the  ana3Sthetic.  These  conditions  are  met  with 
more  frequently  in  muscular  men,  and  especially  those 
addicted  to  strong  drink,  morphine,  chloral,  cocaine  or 
any  sedative  drug,  tobacco,  cigarettes,  etc.  These  pa- 
tients shout,  try  to  leave  the  chair,  swear,  and  show  a 
decided  disposition  to  become  pugilistic.  Doing  such 
struggling   if  nitrous   oxid   or   ether   is   being  used,   a. 


General  Ancesthetics  in  Dentistry.  277 

restriction  of  air  is  indicated.  \\"\\\\  chloroform,  eth}^ 
chloride  or  somnoform.  a  freer  admission  of  air  is  in- 
dicated. Closely  questioning  the  patient  will  usually 
unravel  the  mystery. 

A  vaudeville  singer,  some  weeks  since,  came  to  be 
anaesthetized  for  the  extraction  of  a  tooth.  I  selected 
somnoform.  From  the  first  inhalation  his  muscles 
commenced  to  contract.  His  fingers  doubled  back 
towards  his  w^rist,  his  knees  were  drawn  up  in  close 
proximity  to  his  chin  and  all  of  his  muscles  were  vio- 
lently contracted.  Upon  inquiry,  afterwards,  it  devel- 
oped that  he  was  a  confirmed  cigarette  smoker,  a  verit- 
able fiend.  Once  or  tAvice  when  he  returned  to  the 
office  he  was  as  stupid  and  dull  as  if  under  the  influ- 
ence of  opium.  He  said  he  would  give  all  he  possessed 
to  be  cured.  Go  into  the  history  of  these  cases  and  a 
reason  nearly  alwa3^s  develops. 

In  a  few  exceptional  cases,  anaesthetics  produce 
maniacal  or  delirious  symptoms.  These  are  more  com- 
mon to  nitrous  oxid  and  ether  than  to  ethyl  chloride, 
chloroform  and  somnoform. 

In  the  case  of  women  and  little  girls,  the  lady  assist- 
ant should  make  inquiry  as  to  how  long  it  has  been 
since  the  water  closet  was  visited,  and  you  can  do  the 
same  when  the  patient  is  a  male.  There  is  an  advan- 
tage in  having  the  bladder  emptied  just  before  anaes- 
thetizing a  patient  as  it  may  prevent  an  embarrassing 
and  decidedly  uncomfortable  situation.  In  an  anaes- 
thetic practice  of  more  than  twenty-five  years.  I  have 
only  had  four  cases  of  urination  during  the  anaesthesia 
and   no   case   of   defecation.     The   former   could   have 


278  General  AncEsthetics  in  Dentistry. 

been  avoided,  had  the  proper  inquiry  been  made  and 
the  suggestion  I  am  now  making  carried  out.  I  am 
satisfied  that  I  have  prevented  many  such  occurrences 
by  taking  the  precaution  here  mentioned. 

The  dangers  that  may  arise  and  have  to  be  met  in 
administering"  anesthetics  may  be  classified  under  three 
heads,  namely : 

Respiratory  Arrest. 

Circulatory  Failure. 

Rupture  of  a  Blood  Vessel. 

The  most  important  of  these  is-  respiratory  arrest. 
Most  of  the  mortalities  that  occur  during  anaesthesia 
are  primarily  respiratory  rather  than  circulatory.  Cir- 
culatory failure  is  nearly  always  of  secondary  origin, 
following  sooner  or  later  respiratory  arrest. 

The  dental  surgeon  who  contemplates  employing 
anjesthetics  in  his  practice  should  make  a  study  of  Re- 
spiration, Circulation  and  Reflex  Action.  He  is  deal- 
ing with  these  conditions  every  moment  from  the  time 
his  patient  opens  the  office  door  till  the  effects  of  the 
anaesthetic  have  entirely  passed  away,  and  the  patient 
has  returned  to  the  normal.  You  will  pardon  me,  then, 
if  I  consider  these  subjects  at  some  length  and  find  it 
necessary  to  repeat  some  things  already  dwelt  upon  in 
speaking  of  the  various  anaesthetics,  individually,  in  pre- 
vious lectures.  There  is  this  advantage  in  so  doing ; 
namely,  ,it  places  within  the  scope  of  a  few  pages  data 
that  may  be  wanted  for  reference,  which  otherwise 
would  have  to  be  searched  out  in  fragments  from  a 
number  of  lectures. 


General  Ancesthetics  in  Dentistry.  279 

Respiratory  Arrest. 

In  health,  breathing  progresses  so  regularly  and 
continuously,  both  when  awake  and  asleep,  that  we 
seldom  give  it  a  thought.  The  air  we  breathe  passes 
through  the  nares  into  the  'pharynx,  thence  into  the 
larynx  to  the  trachea  through  the  glottis,  then  through 
the  right  and  left  bronchi  into  small  tubes,  and  from 
these  into  the  air-cells  of  the  lungs  themselves. 

The  lungs  are  spungy  and  elastic,  gray  in  color, 
and  contain  about  8,000,000  air-cells.  It  is  said  that 
the  lungs  present  a  surface,  120  times  greater  than 
that  of  the  entire  body.  In  these  cells  the  blood  comes 
in  contact  with  the  oxygen  of  the  air,  absorbs  it,  and 
gives  in  return  the  poisonous  gas,  carbon  dioxide. 

The  lungs  may  be  considered  as  a  bellows.  This 
bellows  may  be  perfect  in  construction ;  yet,  like  any 
other  bellows,  does  not  work  without  a  motive  power. 
The  motive  power  in  this  case  is  the  respiratory  center 
located  in  the  medulla  oblongata.  Both  of  these  or- 
gans may  be,  in  themselves,  in  excellent  condition, 
and  each  capable  of  performing  its  independent  func- 
tion, yet  they  are  dependent  one  upon  the  other.  The 
respiratory  center  may  give  the  signal  to  the  bellows 
to  begin  to  pump  and  actually  turn  on  the  power,  but 
if  the  respiratory  channel  be  obstructed  or  lung  expan- 
sion prevented,  the  command  cannot  be  obeyed.  On 
the  other  hand,  there  may  be  no  occlusion  or  stenosis 
of  the  air-channel,  and  the  bellows  be  in  excellent  work- 
ing order,  but  it  can  not  start  if  the  respiratory  center 
does  not  furnish  the  motive  power  to  the  muscles  ol 


280  General  Ancesihetics  in  Dentistry. 

respiration.  At  the  great  St.  Louis  exposition,  the 
day  arrived  when  all  the  details  had  been  completed, 
and  the  machinery  was  ready  to  do  its  work,  and  the 
vast  affair  held  its  breath,  as  it  were,  till  Theodore 
Roosevelt,  a  thousand  miles  away  in  Washington 
touched  a  button,  and  the  St.  Louis  exposition  breathed 
and  was  a  thing  of  life,  and  a  million  wheels  sprang 
into  action. 

In  administering  anzesthetics,  it  is  important  to 
proceed  in  so  quiet  and  orderly  a  manner  as,  on  the 
one  hand,  not  to  cause  any  interference  with  the 
bellows  and,  on  the  other,  not  to  impair  or  imduly  dis- 
turb the  respiratory  center  in  the  brain.  When  the 
bellows  is  prevented  from  working  because  of  an  ob- 
structed respiratory  channel  or  lung  expansion,  it  is 
spoken  of  as  mechanical  arrest  of  breathing.  When 
the  respiratory  center  fails  to  respond,  it  is  spoken  of 
as  paralytic  arrest  of  breathing.  Mechanical  arrest 
of  breathing  may  be  a  matter  of  very  little  importance 
and  it  may  be  very  grave.  Paralytic  arrest  of  breath- 
ing in  always  a  serious  condition. 

Following  Hewitt  there  are  three  distinct  ways  in 
which  obstructive  arrest  of  breathing  may  take  place. 
It  may  result  (1)  from  occlusion  of  the  upper  air- 
passages,  such  occlusion  being  produced  either  by  (a) 
spasm,  (b)  swelling,  or  (c)  altered  position  of  parts 
within  or  about  the  upper  air-tract;  (2)  from  the  pres- 
ence of  some  adventitious  substance  within  the  upper 
air-passages;  (3)  from  some  condition  which  directly 
prevents  lung  expansion. 

On  llic  other  hand,  in  paralytic  cessation  of  breath- 


General  Ancesthetics  in  Dentistry.  281 

ing,  respiration  simply  comes  to  a  standstill  as  the 
result  of  failure  of  nerve  energy.  This  failure  may  be 
(1)  toxic,  i.  e.,  from  an  overdose  of  the  ansesthetic 
act  upon  the  respiratory  center ;  (2)  anaemic,  i.  e., 
from  cerebral  anaemia  due  to  fall  of  blood  pressure ;  or 
(3)  reflex  (?),  i.  e.,  from  surgical  or  other  stimuli  inhib- 
iting the  action  of  the  respiratory  center. 

Mechanical  obstruction  arising  from  spasm  of  the 
muscles  in  the  upper  air  passage  can  usually  be 
avoided  by  giving  attention  to  the  strength  of  the 
anaesthetic  vapor  employed.  The  vapor  in  the  begin- 
ning must  not  be  strong  enough  to  act  as  an  irritant. 
It  should  not  produce  coughing,  sneezing,  swallowing 
or  holding  of  the  breath.  It  should  be  sufficiently 
diluted  as  to  hardly  be  noticeable  by  the  patient  and 
its  strength  gradually  increased.  Thus  administered 
spasm  of  the  muscles  of  the  throat  will  not  occur. 

The  treatment  in  these  cases,  arising  from  too  con- 
centrated a  vapor  or  as  the  result  of  excluding  too 
much  air,  is  to  remove  the  inhaler  from  the  face  and 
allow  the  patient  to  breathe  all  air  till  normal  respira- 
tion is  restored  then  adjust  the  inhaler  again,  admitting 
a  large  volume  of  air  and  very  little  of  the  anaesthetic 
vapor,  thus  avoiding  irritation. 

A  thorough  examination  of  the  nares  and  throat 
should  be  made  to  ascertain  if  the  air-way  is  already 
partly  occluded  or  not.  If  such  an  examination  re- 
sults in  disclosing  the  presence  of  hypertrophied  tur- 
binated bones,  nasal  polypi,  adenoid  vegetations  In 
the  upper  pharynx,  enlarged  tonsils,  or  any  other  ab- 
normal growths,  the  patient  is  a  poor  breather.     More 


282  General  Ancesthetics  in  Dentistry. 

care  must  be  exercised  in  the  case  of  such  a  patient 
than  if  the  air-way  contained  no  obstructions.  If  the 
choice  for  a  major  operation  was  to  be  made  between 
ether  and  chloroform,  other  things  being  equal,  chloro- 
form would  be  my  selection  for  this  patient.  Ether 
is  very  irritating  and  causes  secretion  of  mucus,  and 
in  these  conditions  large  quantities  of  mucus  are  al- 
ways present,  while  chloroform  administration  would 
not  be  productive  of  mucus  secretion.  If  the  opera- 
tion in  question  could  be  performed  under  nitrous  oxid 
or  somnoform  angesthesia,  for  such  a  patient  as  de- 
scribed, I  would  select  somnoform.  Nitrous  oxid 
causes  an  enlargement  of  the  tongue  and  all  the  soft 
tissues  from  venous  engorgement.  The  mucous  mem- 
brane of  the  nares  would  be  swollen  from  engorgement 
of  blood,  so  would  the  already  enlarged,  turbinated 
bones,  adenoid  vegetations  and  tonsils,  and  we  would 
make  a  bad  condition  worse.  Somnoform  does  not 
cause  any  enlargement  of  these  tissues  and  would  be 
productive  of  a  more  comfortable,  a  safer  and  a  pro- 
founder  anaesthesia. 

The  most  successful  treatment  in  these  cases  is 
prophylactic  treatment.  Prevent  the  occurrence  of 
the  condition  under  discussion  by  selecting  an  anaes- 
thetic agent  that  is  palliative  rather  than  productive  of 
the  condition  we  seek  to  avoid.  Judgment  and  com- 
mon sense  can  be  used  to  excellent  advantage  in  both 
selecting  and  administering  anaesthetics.  A  mouth- 
prop  should  always  be  adjusted  when  an  anassthetic 
is  to  be  administered  for  a  dental  operation.  With  the 
mouth  open,  the  tongue  can  be  observed  without  diffi- 


General  Andosthefics  in  Dentistry.  283 

culty.  If  the  patient  suddenly  makes  a  loud  snoring 
sound,  and  the  breathing  has  the  appearance  of  being 
interrupted,  take  the  inhaler  away  from  the  mouth 
and  examine  the  tongue  to  ascertain  if  it  has  been  swal- 
lowed. If  so,  grasp  it  with  a  tongue  forceps,  but,  if  one 
is  not  handy,  a  napkin  will  do  as  well.  Unless  you 
have  a  dry  cloth  of  some  kind,  the  tongue  will 
be  found  too  slippery  to  hold  with  the  fingers.  If 
nothing  is  at  hand  with  which  to  grab  the  tongue,  it 
can  usually  be  pushed  to  one  side  unjcil  the  assistant 
can  hand  you  a  napkin  or  an  instrument.  I  have  never 
experienced  any  difficulty  with  tongues  in  my  anaes- 
thetic work.  I  witnessed  an  interesting  case  at  Min- 
neapolis, during  a  meeting  of  the  State  Dental  Society, 
three  years  ago.  A  young  man  was  exhibiting  and 
demonstrating  the  use  of  a  new  nitrous  oxid  appliance. 
As  no  one  seemed  sufficiently  interested  to  take  the 
anaesthetic,  every  few  minutes  he  would  secure  a  new 
audience  and  take  the  nitrous  oxid  himself.  Something 
happened  to  the  nasal  inhaler  so  it  did  not  work  satis- 
factory, and,  after  repairing  it,  he  slipped  it  on  his 
nose  to  test  its  efficiency.  He  was  alone  this  time. 
The  crowd  in  another  part  of  the  room  were  attracted 
by  a  terrible  crash,  and  we  went  over  in  the  direction 
of  the  noise  to  see  what  had  happened.  We  found 
the  nitrous  oxid  salesman  on  the  floor,  his  face  a  deep 
purple.  He  was  snoring  loudly  and  one  of  the  dentists 
present  recognized  the  difficulty,  took  his  handker- 
chief and  pulled  forward  his  tongue.  The  nasal  in- 
haler was  still  strapped  on  his  nose  and  I  went  over 
and  took  that  off.    He  remained  quiet  a  little  while  and 


284  General  Ancesthetics  in  Dentistry. 

got  up,  and  I  do  not  think  he  knew  that  anything 
unusual  had  happened.  He  made  the  following  re- 
mark which  greatly  amused  those  present:  "No  matter 
how  much  nitrous  oxid  I  inhale,  I  never  yet  have 
swallowed  my  tongue."  Had  this  man  been  in  the 
room  alone,  he  would  surely  have  died  from  asphyxia- 
tion because  his  tongue  had  been  swallowed,  thus  in- 
terfering with  respiration.  He  was  anaesthetized  to 
the  point  of  insensibility  and  the  nasal  inhaler  was 
strapped  on,  and  there  could  have  been  no  other  result. 


General  Anxsihetics  in  Dentistry.  285 


LECTURE  XXII. 

Difficulties    and    Dangers    Incident    to    Administering 

General  Anaesthetics  in  Dental  Practice  and 

How  to   Meet  Them — Continued. 

The  presence  of  some  adventitious  or  foreign  mat- 
ter in  the  throat  is  the  condition  I  dread  the  most  in 
my  anaesthetic  work.  I  have  never  been  afraid  of 
spasm  arising  from  any  other  cause,  or  of  respiratory 
arrest  or  circulatory  failure  from  paralysis,  the  result 
of  an  overdose  of  aneesthetic, — none  of  these  things 
annoy  me  in  the  least,  but  I  am  apprehensive  lest  some- 
time I  may  have  trouble  from  blood  accumulating  in  the 
pharynx  or  larynx,  the  weight  and  presence  of  which 
might  refiexly  cause  paralysis  of  respiration.  Avoid- 
ance of  the  accumulation  of  blood  in  the  throat  is  the 
one  thing  about  which  I  am  more  careful,  if  possible, 
than  any  other  in  my  ancesthetic  practice. 

With  some  patients,  the  blood  clots  very  quickly 
and  I  have  often  seen  in  an  ordinary  nitrous  oxid  or 
somnoform  anaesthesia,  the  blood  become  almost  as 
solid  and  tenacious  as  a  hunk  of  liver.  Hewitt  men- 
tions removing  from  the  throat  a  conglomerated  mass 
of  clotted  blood  four  inches  long  in  an  extracting  case. 
Where  there  is  profuse  hemorrhage  at  the  time  of  ex- 
tracting under  nitrous  oxid  or  somnoform.  I  frequently 


286  General  Ancesihetics  in  Dentist)- y. 

cease  operating,  when  other  teeth  could  be  removed,  :n 
order  to  take  care  of  the  rapidly  accumulating  blood. 
There  is  a  stage  in  both  nitrous  oxid  and  somnoform, 
with  some  patients,  in  which  there  is  a  contraction  of 
all  the  throat  muscles,  during  which  time  the  patient 
can  neither  spit  or  swallow.  I  am  always  on  the  alert 
for  this  condition  in  cases  of  profuse  hemorrhage.  I 
do  not  throw  my  chair  back  very  far  even  when  operat- 
ing on  the  upper  teeth  and  I  am  very  careful  that  little 
or  no  blood  gets  in  the  throat  while  operating. 

My  assistant  is  over  or  under  the  socket  with  a  nap- 
kin almost  as  soon  as  I  have  the  tooth  or  teeth  out. 
We  use  the  ordinary  Johnson  &  Johnson  four-inch 
dental  napkins  for  this  purpose.  Two  or  three  of  these 
are  rolled  together  and  cut  in  two,  making  them  about 
two  inches  tall.  These  are  tied  about  the  center  with  a 
string  of  different  color  from  that  about  the  mouth- 
prop.  When  but  two  or  three  teeth  are  extracted  these 
are  crowded  immediately,  just  as  the  mouth-prop  is 
used,  over  or  under  the  extracted  tooth  or  teeth,  and 
allowed  to  remain  there  till  the  patient  is  perfectly  con- 
scious and  able  to  clear  and  rinse  the  mouth.  Then, 
just  before  removing  the  mouth-prop,  pull  these  nap- 
kins out  by  their  string.  Never  take  the  mouth-prop 
out  first..  Where  several  teeth  are  removed,  crumple 
the  napkins  in  the  hand  and  use  these  as  a  surgical 
sponge  till  the  patient  recovers.  If  blood  should  accu- 
mulate in  the  throat,  and  the  patient  does  not  swallow 
it  or  is  not  successful  in  coughing  it  up,  lean  him  for- 
ward, slap  him  on  the  back,  and  if  he  gets  cyanotic  and 


General  Ancesthetics  in  Dentistry.  287 

does  not  breathe,  hold  him  up  by  the  feet,  the  assistant 
slapping  the  back. 

If  the  patient  becomes  nauseated,  vomit  may  come 
up  into  pharynx  and  larynx  and  produce  exactly  the 
same  condition  as  accumulated  blood.  The  treatment  is 
the  same  as  that  for  the  former  condition. 

The  collection  of  particles  of  regurgitated  food  and 
mucus  in  the  larynx  produce  symptoms  sometimes  that 
are  mistaken  for  a  much  more  alarming  condition.  This, 
in  some  patients,  leads  to  labored  breathing,  cyanosis, 
feeble  pulse,  and  sometimes  pallor  is  mistaken  for 
surgical  shock  or  "syncope." 

Great  care  should  be  taken  that  extracted  teeth  or 
roots  do  not  find  their  way  into  the  throat.  Be  sure 
that  every  tooth  is  dislodged  from  the  forceps  and  is 
dropped  on  the  outside  of  the  mouth  before  extracting 
another.  Portions  of  enamel  often  fracture  and  fly  into 
the  throat,  and  roots  are  apt  to  do  the  same ;  for  this 
reason  one  must  be  exceedingly  careful  in  using  ele- 
vators when  extracting  under  an  anaesthetic.  Frag- 
ments of  teeth,  amalgam  fillings,  loose  crowns,  may 
easily  get  mixed  up  with  the  blood  and  saliva  and  pass 
into  the  throat.  If  these  are  swallowed,  but  little  harm 
arises,  but  it  becomes  a  serious  matter  when  they  find 
their  w^ay  into  the  bronchi  or  lungs. 

"In  a  case  reported  by  Mr.  Claremont.  some  frag- 
ments of  teeth  entered  the  larynx  during  chloroform 
anaesthesia.  When  the  patient  became  conscious,  after 
the  operation  was  over,  coughing  occurred,  and  a  com- 
plaint was  made  of  soreness  about  the  chest. 
There  were,  however,  at   the  time,  no  distinct  symp- 


288  General  AncBsthetics  in  Dentistry. 

toms  of  the  presence  of  the  fragments.  General  bron- 
chitis followed.  Subsequently,  the  fragments  were 
coughed  up  from  the  lungs  and  the  patient  made  a 
good  recovery. 

"A  case  is  also  mentioned  in  the  Dublin  Medical  and 
Chernical  Journal,  in  which  the  roots  of  a  lower  molar 
entered  the  right  bronchus  after  extraction.  Death 
supervened  in  eleven  days. 

"Another  case  is  reported  in  the  Edinbourgh  Jour- 
nal, in  which  an  entire  lower  molar  entered  the  lung. 
It  was  coughed  up  on  the  eleventh  day  and  the  patient 
recovered. 

"In  the  British  Journal  of  Dental  Science,  January, 
1879,  a  case  is  related  in  which  a  large  amalgam  filling 
shot  from  a  tooth  during  extraction  under  nitrous  oxid, 
and  presumably  entered  the  larynx.  Fortunately  tlie 
patient  coughed  it  out  immediately  after  the  effects 
of  the  anaesthetic  had  passed  off. 

"In  a  case  referred  to  in  the  British  Medical  Journal, 
February,  1899,  an  extracted  tooth  entered  the  larynx 
during  nitrous  oxid  anaesthesia,  causing  extreme  cyan- 
osis. Subsequently  there  was  a  feeling  of  tightness  in 
the  throat,  aggravated  by  speaking  or  by  change  of 
posture.  No  breath  sounds  were  audible  over  the  left 
lung.  Death  took  place  in  twelve  days.  At  the  ne- 
cropsy the  tooth  was  found  in  the  left  bronchus. 

"A  case  has  lately  been  reported  to  the  author  in 
which  a  medical  man,  while  sponging  out  the  throat 
during  a  dental  operation  under  ether,  inadvertently 
pushed  an  extracted  tooth  backwards.  It  was  hoped 
that  the  patient  had  swallowed  the  tooth.     For  three 


General  Ancesihetics  in  Dentistry.  289 

weeks  she  suffered  from  certain  chest  symptoms,  which 
she  ascribed  to  the  anaesthetic.  At  the  end  of  this 
time  the  tooth  was  coughed  up  and  no  furtlier  trouble 
followed."  (Hewitt.) 

Respiratory  arrest,  the  result  of  paralysis  of  the 
respiratory  center  in  the  medulla  oblongata,  is  a  more 
serious  and  complicated  condition  than  the  variety  of 
respiratory  arrest  which  has  just  been  considered.  This 
condition  may  result  primarily  from  an  overdose  of  an- 
aesthetic, from  the  toxic  effect  of  the  drug,  or  cerebral 
anaemia  from  a  lowering  of  the  blood  pressure,  or  by 
reflex  action  resulting  in  inhibition. 

We  are  not  apt  to  encounter  respiratory  arrest,  the 
result-  of  paralysis  of  the  respiratory  center,  in  dental 
practice  if  we  confine  ourselves  to  the  use  of  those 
an;Tf?sthetics  which  have  been  denominated  office  anaes- 
thetics; namely,  nitrous  oxid,  ethyl  chloride  and  som- 
noform.  We  would  hardly  expect  to  get  a  toxic  dose, 
if  these  agents  accumulated  in  the  system,  because  of 
the  brevity  of  their  action  and  their  rapid  elimination. 
We  would  not  expect  cerebral  anaemia  from  diminution 
of  blood  pressure,  because  the  three  an?esthetic  agents 
mentioned  are  all  stimulating  in  their  action,  and  pro- 
duce an  increased  blood  pressure.  Reflex  action  result- 
ing in  inhibition  usually  is  the  result  of  exposure  or 
handling  the  vital  organs,  severing  a  large  nerve  or  the 
like  in  major  operations.  If  this  condition  arose  at  all 
in  dental  practice,  it  would  probably  be  the  result  of 
ether  or  chloroform  administration  and  if  you  adopt 
the  plan  recommended  in  these  lectures  of  having  a 
physician  always  administer  ether  or  chloroform  when 


290  General  Ancesthetics  in  Dentistry. 

indicated,  the  responsibility  would  not  be  yours  if  this 
condition  should  arise.  You  will  recall,  I  recom- 
mended, that  the  anaesthetic  vapor  should  be  adminis- 
tered in  a  very  dilute  form  in  the  very  beginning  of  in- 
duction. If  this  suggestion  be  carried  out,  there  is 
very  little  danger  of  inhibition  by  reflex  action  in  the 
early  stages  of  anaesthesia. 

Respiratory  arrest,  the  result  of  paralysis  of  the 
respiratory  center,  usually  comes  on  gradually.  Res- 
piration slows  down ;  the  inspirations  are  not  so  deep 
and  become  lighter  and  more  shallow.  The  pupil  is 
usually  dilated;  the  color  becomes  more  and  more 
dusky  or  pale  sometimes ;  the  eye-lids  contract ;  the 
pulse  becomes  lighter  and  more  feeble.  Respiration 
ceases,  but  the  heart  continues  its  action,  sometimes  for 
several  minutes.  When  this  condition  arises  from  a 
toxic  effect,  it  is  more  common  to  chloroform  than  any 
other  anaesthetic.    Chloroform  is  a  protoplasmic  poison. 

Respiratory  arrest  arising  from  paralysis  of  the  res- 
piratory center  depending  on  anaemia  is  the  result 
of  cardio-vascular  paralysis  which  in  turn  results  from 
an  overdose,  or  it  may  arise  as  the  result  of  anaemia  de- 
pending on  circulatory  failure,  or  from  lowering  blood 
pressure  from  an  upright  position. 

These  cases  demand  prompt  treatment.  If  the  con- 
dition is  observed  in  its  incipiency,  discontinue  the  an- 
aesthetic and  lower  the  patient,  if  in  the  sitting  pos- 
ture or  if  the  head  is  somewhat  elevated.  Satisfy  your- 
self by  examining  the  fauces  that  there  is  no  obstruc- 
tion to  the  passage  of  air  into  the  lungs  from  collection 
of  mucus  or  swallowing  of  the  tongue  or  regurgitated 


General  Anoesthehcs  in  Dentistry.  291 

food  from  the  stomach.  If  no  mechanical  obstruction 
is  present  and  respiration  does  not  improve,  then  re- 
sort immediately  to  artificial  respiration. 

If  the  condition  tmder  consideration  should  arise  in 
a  dental  chair,  place  the  patient  as  quickly  as  possible 
on  the  floor.  Slip  a  pillow  or  a  cushion  under  the 
shoulders  to  elevate  them  which  permits  the  head  to 
fall  backward,  slightly. 

If  the  patient  is  on  a  surgical  table  slide  the  body 
along  till  the  neck  is  on  a  level  with  the  table  and  this 
position  will  allow  the  head  to  fall  over  the  end  of  the 
table. 

If  a  bed  is  being  substituted  for  a  surgical  table, 
place  the  patient  across  the  bed  so  the  head  will  drop 
backward  over  the  side  of  the  bed.  This  is  the  proper 
position  for  artificial  respiration  and  the  Silvester 
method  is  considered  the  best. 

The  anesthetist  should  stand  back  of  the  patient 
and  grab  each  arm  just  above  the  elbow.  Press  the 
arms  of  the  patient  firmly  and  steadily  against  the 
chest.  This  pressure  usually  causes  the  patient  to  ex- 
pire or  make  an  expiration.  If  not  successful,  a  quick 
pressure  forcibly  exerted  below  the  ribs  towards  the 
diaphragm  should  next  be  made.  Hold  the  arms  in 
this  position  for  about  two  seconds,  then  steadily  and 
evenly  draw  them  backward  as  far  as  possible  till  they 
are  in  line  with  the  extended  body.  The  object  of  this 
is  to  enlarge  the  capacity  of  the  chest,  the  pectoral 
muscles  raising  the  upper  ribs,  and  thus  to  produce  an 
inspiration.  The  arms  should  be  held  in  this  extended 
position  about  two  seconds.     Then  return  them  rhyth- 


292  General  Ancesihetics  in  Dentistry. 

mically  to  the  side  and  press  the  chest  again.  This 
should  be  continued  at  the  rate  of  fifteen  times  per 
minute.  Watch  carefully  for  a  return  of  respiration 
and  aid  it  till  it  is  normally  re-established.  Do  not 
become  discouraged.  Patients  are  sometimes  resusci- 
tated after  physicians  have  given  up  the  case  as  hope- 
less. A  very  prominent  Chicago  dentist  succeeded  in 
resuscitating  his  own  wife  two  hours  after  physicians 
had  pronounced  the  case  hopeless  and  taken  their  de- 
parture. Chloroform  was  the  arnsesthetic  used  in  this 
case. 

In  the  Marshall  Hall  method  of  artificial  respiration 
the  patient  is  placed  face  downward  and  he  is  rolled 
to  his  side  gently,  then  back  again  about  fifteen  times 
per  minute.  When  in  the  prone  position  make  pressure 
on  the  back,  then  roll  to  the  side  again. 

There  are  other  methods  of  artificial  respiration, 
but  the  Silvester  method  meets  the  requirements  better 
than  the  others. 

While  the  anzesthetist  is  busy  with  the  arm  manip- 
ulation the  tongue  should  be  grasped  with  a  forceps 
and  rhythmical  traction  made.  If  the  heart  is  bea:ting, 
a  hypodermic  injection  of  strychnia,  1-20  of  a  grain, 
should  be  made  to  further  stimulate  the  heart's  action. 
Drugs,  however,  are  not  considered  of  much  avail  in 
this  form  of  respiratory  arrest  by  Hewitt  and  others. 

Circulatory  Failure. 

Circulatory  failure  is  a  condition  the  dental  surgeon 
is  not  apt  to  see  if  he  confines  himself  to  the  use  of 
nitrous   oxid,   somnoform   and   ethyl   chloride.      These 


General  Ancesthetics  in  Dentistry.  293 

agents  are  sometimes  productive  of  respiratory  arrest, 
which,  of  course,  would  be  followed,  if  not  relieved,  by 
circulatory  failure.  Post-mortem  examinations  follow- 
ing death  from  both  nitrous  oxid  and  ethyl  chloride 
point  to  paralysis  of  the  respiration  as  the  cause  of 
death. 

There  is  nearly  always  impairment  of  breathing 
prior  to  circulatory  failure.  It  behooves  us  therefore 
always  to  carefully  watch  the  respiration  no  matter 
what  may  be  the  anaesthetic  agent  employed.  And  the 
pulse  should  be  watched  as  closely  as  the  respiration. 
It  is  an  easy  matter  in  administering  an  anaesthetic 
for  dental  purposes  to  keep  the  finger  of  the  left  hand 
on  the  temporal  artery  till  you  are  ready  to  operate  if 
the  operation  be  one  of  extraction,  and,  if  you  are  to 
operate  on  the  teeth,  the  assistant  can  be  taught  to  hold 
her  finger  on  the  artery  of  the  left  wrist  and  inform 
you  if  there  is  an  abnormality. 

The  treatment  of  circulatory  failure  is  first  to  dis- 
continue the  anaesthetic,  quickly  get  the  patient  in  a 
horizontal  position,  and  stimulate  the  breathing.  The 
respiration  must  be  taken  care  of  first  always.  If  there 
is  not  an  abundance  of  help  present,  the  one  thing 
above  all  others  to  do  first  is,  begin  artificial  respira- 
tion. "In  comparatively  minor  cases,  while  respiration 
is  still  continuing,  all  that  is  needed,  as  a  rule,  is  to  rub 
the  lips  briskly  and  to  assist  the  feeble  respiratory  ef- 
forts by  chest  compression.  These  measures  will  often 
ward  off  a  more  alarming  state,  the  pulse  and  color 
quickly  improving  in  response  to  this  simple  treat- 
ment."     (Hewitt.) 


294  General  Ancesthetics  in  Dentistry. 

In  the  graver  cases,  partial  or  complete  inversion  of 
the  patient  was  first  advocated  by  Nealton.  Schuppert 
claims  to  have  saved  three  patients  by  inversion.  Oth- 
ers report  remarkable  success  accompanying  inversio'n. 
The  argument  is  that  respiratory  action  is  stimulated 
by  an  increased  cerebral  blood  supply. 

If  this  measure  fails,  massaging  the  muscles  over 
the  heart  may  be  resorted  to.  This  may  be  done  as  an 
adjunct  to  the  Silvester  method  of  artificial  respiration. 
If  a  second  party  be  present,  the  muscles  over  the  heart 
may  be  massaged  at  the  time  that  artificial  respiration 
is  progressing. 

"Drugs  are  of  little  if  any  service  in  cases  of  this 
class,  and  if  employed  should  be  administered,  not  by 
the  anaesthetist,  but  by  some  other  person  present.  The 
anaesthetist's  undivided  attention  must  be  devoted  to 
maintaining  efficient  artificial  respiration  and  a  proper 
posture.  To  commence  the  treatment  of  a  marked  case 
of  syncope  by  a  hypodermic  injection  of  ether  or 
brandy  is  not  only  useless  (seeing  that  the  circulation 
is  more  or  less  suspended)  but  dangerous,  in  that  such 
a  procedure  delays  the  application  of  artificial  respira- 
tion, the  remedial  measure  by  which  the  elimination  of 
the  anaesthetic  and  aeration  of  the  blood  are  affected 
and  the  measure  of  all  others  which  is  most  likely  to 
increase  cardiac  action.  There  is,  of  course,  no  objec- 
tion to  the  employment,  by  sortie  other  person  than  the 
anaesthetist,  of  such  drugs  as  ammonia,  nitrate  of  amyl, 
strychnine,  or  caffine;  but  these  substances  should  only 
be  used  as  adjuncts,  and  in  the  manner  described." 
(Hewitt.) 


General  Ancesthetics  in  Dentistry.  295 

Rhythmical  compression  of  the  muscles  above  and 
around  the  heart  may  be  accomplished  by  pressing  the 
right  thumb  between  the  sternum  and  the  apex  of  the 
heart  on  the  left  side,  the  left  hand  being  placed  over 
the  thorax  to  steady  the  body.  Compression  should  be 
made  about  seventy-five  times  per  minute. 

Slapping  the  face  with  towels  wet  with  cold  water 
stimulates  circulation  reflexly. 

In  the  earlier  stages  ammonia  nitrate  and  amyl 
nitrite  are  thought  by  some  to  be  beneficial.  The  amy] 
nitrite  is  put  up  in  glass  pearls  which  are  crushed  on  a 
napkin  and  held  under  the  nose. 

A  nitroglycerine  tablet  of  the  strength  of  1-100 
placed  on  the  tongue  quickly  dissolves. 

In  regard  to  the  treatment  of  circulatory  failure  due 
to  surgical  procedure,  there  is  a  difference  of  opinion 
among  the  authorities.  Crile  and  Mummery  agree  that 
strychnia  is  useless  in  these  cases.  Crile  found  by 
experiment  that  repeated  injection  of  strychnia  in 
healthy  animals  produced  shock.  Only  in  animals 
with  mild  degrees  of  shock  was  strychnia  of  service ; 
and,  as  soon  as  the  efTect  passed  off,  these  suffered  a 
deeper  degree  of  shock.  Crile  also  makes  the  claim  that 
in  the  intra-venous  injection  of  alcohol  there  was  gen- 
erally a  fall  in  the  blood  pressure,  and,  in  an  animal 
suffering  from  shock,  it  caused  a  further  decrease  in 
blood  pressure.  Mummery  verified  the  findings  of 
Crile  by  tests  made  with  the  sphygmomanometer. 
Crile  has  invented  a  pneumatic  suit  by  the  use  of  which 
he  succeeds  in  raising  the  blood  pressure  or  prevent- 
ing its  fall. 


296  General  Ancesthetics  in  Dentistry. 

In  case  of  cessation  of  breathing,  no  time  must  be 
lost  in  removing  all  obstacles  to  lung  expansion.  Of 
the  thirty-five  nitrous  oxid  deaths  that  have  been  re- 
ported, several  are  known  to  have  been  caused  by  tight 
corsets.  All  tight  clothing  and  bands  must  be  removed 
as  quickly  as  possible,  no  time  is  to  be  lost. 

Respiratory  spasm  under  nitrous  oxid,  somnoform 
and  ether  is  not  as  dangerous  as  the  same  condition 
occurring  during  chloroform  anaesthesia,  because  chlo- 
roform is  a  protoplasmic  poison,  and  this  poison  ac- 
cumulating in  the  system  is  an  added  feature  to  the 
danger.  If  spasm  does  not  subside  upon  loosening  the 
clothing,  the  tongue  should  be  pulled  forward,  any 
mucus  in  the  throat  removed,  the  artificial  respiration 
commenced,  the  patient  being  placed  on  a  table  or  the 
floor  with  the  shoulders  slightly  elevated  and  the  head 
dropped  backward. 

Both  in  respiratory  arrest  and  circulatory  depres- 
sion admission  of  air  to  the  lungs  is  worth  more  than 
all  the  drugs  in  the  pharmacopcEia.  In  an  experience 
of  more  than  twenty-five  years  with  anaesthetics  in 
dental  practice,  the  writer  has  never  found  it  necessar)'- 
to  use  the  hypodermic  syringe  or  resort  to  the  use  of 
drugs  or  stimulants  on  account  of  either  circulatory 
depression  or  respiratory  arrest.  He  recognizes  the 
importance,  however,  of  being  prepared  for  an  emer- 
gency, and  the  man  who  is  administering  an  anass- 
thetic,  whether  physician  or  dentist,  should  have  every 
agent  and  remedy  at  hand  that  might  be  needed  in  case 
an  accident  should  happen.    With  this  end  in  view,  the 


General  Ancesthetics  in  Dentistry.  297 

writer  advises  that  you  provide  yourself  with,  and  have 
within  reach,  the  following: 

1.  A  supply  of  mouth-props. 

2.  One    or    more    tongue     depressors    or    tongue 
guards. 

3.  A  tongue  forceps. 

4.  A  hypodermic  syringe  and  needles. 

5.  Hypodermic  tablets  of  strychnia  sulphate,  1-20 
grain. 

6.  Hypodermic   tablets   of    nitro-glycerine,    1-100 
grain. 

7.  Aromatic  spirits  of  ammonia. 

8.  Brandy. 

9.  Amyl  nitrite  pearls. 

10.  Adrenalin,   1-20,000. 


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